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Description
Hospital-acquired Infections and antimicrobial resistance are among the most serious public health problems also in Europe. Two European Union Council Recommendations have been approved in order to ask European Union Member States to adopt and implement specific strategies for the prudent use of antimicrobial agents - aiming at containing antimicrobial resistance, and for the prevention and control of healthcare-associated infections - aiming at improving patient safety. The impact of antimicrobial resistance goes beyond its severe consequences for human and animal health and has become a global public health concern that affects the whole society and needs urgent and coordinated inter-sectoral action. In Romania, antimicrobial resistance is an important public health threat. Romania is one of the EU Member states with one of the highest levels of antimicrobial resistance, especially in invasive infections. The impact is felt particularly by vulnerable patients, as it can result in prolonged illness and increased mortality.
The project shall support monitoring of antimicrobial resistance and hospital-acquired infections and stewardship on antibiotics prescription through developing National Strategy and National Action Plan, elaboration standards and protocols, antimicrobial resistance testing, hospital-acquired infections surveillance and antibiotic stewardship in public hospitals, as well as professional guidelines, training and capacity-building for health professionals.
The project will be implemented by the National Institute of Infectious Diseases “Prof. Dr. Matei Bals” Bucharest in partnership with the Norwegian Institute of Public Health. Norwegian experiences and good practices regarding antimicrobial resistance and antibiotic consumption will be replicated in the Romanian health system.
Summary of project results
In recent years, antimicrobial resistance (AMR) has posed a threat to the treatment of a multitude of infections caused by bacteria, parasites, viruses and fungi. AMR has the effect of reduced effectiveness of antibacterial, antiparasitic, antiviral and antifungal treatment, which makes the clinical management of the adult patient difficult, financially burdensome or even impossible.
The impact is particularly felt by the vulnerable patient, as AMR leads to prolonged disease duration and increased mortality. The magnitude of the problem, on a global level, but also the impact on human and animal health, on the costs in the relevant sectors, still remain unknown.
The EU One Health conference on AMR, held in Amsterdam in 2016, launched the idea of cooperation, at political level, between EU member states through a One Health Network to combat AMR. The main resolution of the conference was the implementation, in the next half of 2017, of a national action plan against antibiotic resistance, which would align with the One Health approach and the objectives of the WHO Global Plan of Action.
Antimicrobial resistance (AMR) is a serious problem in Romania, with levels of AMR reported in the most common human bacteria high and/or increasing compared to most other EU/EEA countries.
There are several key factors influencing this situation, such as the high rate of consumption of antimicrobial agents in general practice and the use of broad-spectrum antibiotics. Also, it seems that there are problems in the area of hospital infrastructure, but also a lack of skills among the medical staff.
In addition, Romania does not have solid data on the rate of AMR, healthcare-associated infections (HAIs) or on the consumption of antimicrobials, at the local level, to be the subject of specialized guidelines or to issue a set of principles for the administration of antibiotics and infection prevention and control. Other important factors are the lack of collaboration between multidisciplinary networks made up of clinicians, microbiologists and epidemiologists, but also the lack of a collaboration protocol between the fields of human and veterinary medicine regarding AMR.
According to the ESAC 2017 report (https://ecdc.europa.eu/en/antimicrobial-consumption/database/country-overview), antimicrobial resistance in Romania is directly related to antibiotic consumption, which is among the highest in EU/EEA countries. The consumption of antibiotics in Romania in 2016 was high, with 29.54 DDD / 1000 inhabitants / day, which represents the fourth place, after Greece, Cyprus and France, at the European level. Also, the consumption of antibiotics selects for bacterial resistance and induces Clostridium Difficile infections. The most used group of antibiotics was penicillin+ 54.3%, cephalosporins+ 16.8% and quinolones- 11.6%. The broad-spectrum antibiotic use index reached 16.63, which is a continuous increase from 6.4 in 2011 and 11.1 in 2013. Other issues of interest are the increase in the rate of administration of "last resort" antibiotics such as carbapenem and colistin ( the 2nd place to the use of colistin), the increased use of broad-spectrum antibiotics such as cefuroxime, ceftriaxone and levofloxacin but also the frequent use of vancomycin, most likely linked to the high incidence of Clostridium difficile infections (ESAC, 2017, CARMIN report 2015).
The identification, analysis, control and monitoring of infectious risks in public hospitals in Romania are still underreported; reporting of HAIs or incidents/accidents involving occupational risk is still low. Moreover, the measures that restrict the self-administration or abuse of antibiotics are insufficiently promoted and investigated in most hospitals, the monitoring of antibiotic resistance being also suboptimal. This context underlines the need for appropriate interventions to improve the performance and quality of the health system.
According to the recommendations of the Council of Europe, Romania should take rapid steps in the development and approval of a National Strategy and a National Action Plan (NAP) to reduce the risk associated with AMR and to encourage the judicious use of antibiotics in human and veterinary medicine, in compliance with national and European guidelines as well as the improvement of prescribing practices and training of medical personnel, from both sectors.
The NAP must contribute to the strategic objectives, based on the analysis of the current situation and the local context. The NAP must reflect the principles identified in the WHO Global Action Plan:
• the involvement of the entire society, including the "One Health" approach;
• prevention above all;
• ensuring access but avoiding excess
• sustainability of interventions
• expansive targets for implementation.
The main results were achieved through the following activities:
Activity 1: Assessing the current national status of antimicrobial resistance (AMR), the rate of healthcare-associated infections (HAIs) and the way antibiotics are prescribed:
As part of the activity, an Evaluation Report of the existing legislation in the key areas necessary for the control of antimicrobial resistance (AMR) and healthcare-associated infections (HAI) was produced, as well as the framework documents for the National Strategic Framework and the National Action Plan to combat the phenomenon of antibiotic resistance and healthcare-associated infections.
Activity 2: Development of a national strategic framework and a national action plan to combat the phenomenon of antimicrobial resistance and healthcare-associated infections:
• 3 guidelines were developed: infectious diseases, microbiology and laboratory diagnosis and epidemiology.
• The final version of the National Strategic Framework and the National Action Plan was adopted.
Activity 3: Selection of 5 pilot hospitals based on an agreed set of criteria:
With the support of the WHO, 5 pilot hospitals were selected which, together with INBI MB, elaborated the common methodology for antibiotic resistance testing, surveillance of healthcare-associated infections and antibiotic prescribing in the selected hospitals and INBI MB. A Pilot Hospital Evaluation Questionnaire covering the following areas was created and applied: infectious diseases, microbiology, laboratory diagnosis and epidemiology. The questionnaire was a multi-structured work tool on the fields of interest: microbiology, epidemiology, infectious diseases, comprising more than 170 questions, so that the initial and progress evaluation of the hospitals that were piloted was as accurate as possible. Following the application of the questionnaire and after the discussions with the designated persons from the pilot hospitals, six evaluation reports and one aggregate evaluation report resulted.
Activity 4: Develop a curriculum for health professionals (microbiologists, epidemiologists, infectious disease specialists/antibiotic prescribing, other clinicians and nurses):
• the curriculum was developed by medical technical experts from the Romanian side, after consultations with Norwegian experts. The curriculum is adapted for the following target groups: medical microbiologists, epidemiologists, infectious disease specialists/antibiotic prescribing, other clinicians and nurses. Six separate curricula are provided, with six courses each, followed by a final check of acquired knowledge. For each curriculum, a module structure was established with the allocation of a period of time for each module. There have been numerous consultations on how to effectively organize the training sessions, including how Norwegian experts will be involved. In May, a number of 45 courses were held online for doctors of various specialties and nurses from the pilot hospitals.
Of these, three courses were held by experts from the Norwegian Institute of Public Health. Between November 14-18, a study visit took place in Oslo, Norway, attended by 23 doctors from the six pilot hospitals (11 microbiologists, 6 infectious diseases doctors, 1 intensive care doctor and 5 epidemiologists). The Romanian delegation had meetings with experts from the National Institute of Public Health in Norway, a private hospital (Diakonhjemmet Hospital, Oslo) and a university hospital (Akershus University Hospital (Ahus), Oslo).
The last day included a workshop with case study presentations and interactive discussions aimed at raising awareness of the need for partnership between infectious disease specialists, microbiologists, infection control physicians for the effective implementation of antibiotic judicious use and disease control programs. infections. The workshop was attended by experts from the National Institute of Public Health in Norway and the University Hospital in Oslo, together with doctors from the Romanian delegation.
Activity 5: Piloting of tools in 6 hospitals for 12 months (supply of laboratory kits) - laboratory and diagnostic support for prescribing antimicrobial agents and accurate and timely detection of infections caused by resistant pathogens:
This activity was carried out by the Marius Nasta Institute in partnership with the LHL Foundation, during which the following took place:
o 14 health communication courses attended by a total of 288 people, including: 160 medical staff, 128 former TB patients, social workers, vulnerable groups
o Public speaking sessions were organized for former TB patients: 3 public speaking workshops, 5 patients in each workshop
o 6 meetings with volunteers were organized
o A training session was organized for 20 journalists
o The activity was completed on 28.02.2024
Results:
- 20 trained journalists
- 3 training packages developed
- 14 health communication training sessions
- 15 patients included in public speeches
- 288 informed and trained people
Activity 6: Review of the NAP and operational tools:
The NAP revised within a wprkshop was submitted to the Ministry of Health and other relevant central and county authorities.
Activity 7: E-learning platform, hardware and software, with 5 initial modules of the curricula to increase the level of practice and skills of health professionals regarding AMR and HAI (IAAM):
The e-learning platform was developed through own resources by the IT expert. The hardware part of the platform was provided by INBI MB where steps were taken to identify and allocate the necessary resources. The 6 curriculum modules developed and available at https://elearning.mateibals.ro/ were implemented:
• Module 1 - Microbiological doctors (6 courses)
• Module 2 - Medical epidemiologists (6 courses)
• Module 3 - Infectious Disease Doctors, antibiotic prescription (6 courses)
• Module 4 - Medical specialty doctors (6 courses)
• Module 5 - Doctors specializing in surgery and ATI (6 courses)
• Module 6 - Medical assistants (3 courses)
PDP-8 project website: https://elearning.mateibals.ro/prescriere-antibiotice/.
Activity 8: Information, education, communication:
The project launch and closing conference, press conferences with central and local authorities in the field were organized, 6 newsletters, brochures, communication materials were published, a project presentation film was developed and broadcast, information activities and promotion of the project at the national microbiology and epidemiology conference.
Antimicrobial resistance is a global threat, which has been recognized by the World Health Organization, the European Union and the governments of many countries as a major public health problem. AMR is a complex problem that affects the whole of society and is determined by a multitude of interconnected factors. In the absence of effective antimicrobials for the prevention and treatment of infections, advances in modern medicine such as organ transplantation, cancer chemotherapy, immunocompromised patient management, major surgery, including robotic surgery, are compromised. To minimize the occurrence and spread of AMR, a coordinated and integrated cross-sector action plan is needed. Individual and isolated interventions have been observed to have only limited impact on this major public health problem
With the help of the National Institute of Public Health in Norway, the National Strategic Framework and the draft National Action Plan were developed.
3 operational tools were developed: Infectious diseases guide – preliminary version, Epidemiology guide – preliminary version, Microbiology and laboratory diagnosis guide.
The Methodology and the set of criteria were developed in order to select the 5 pilot hospitals that participated in the piloting of the developed instruments, together with INBI Matei Bals
Methodology for antimicrobial resistance testing, healthcare-associated infection surveillance and antibiotic prescribing
There were 168 specialists trained based on the 3 curricula (microbiologists, epidemiologists, specialists in infectious diseases, antibiotic prescription), 90 nurses trained, 90 clinicians (other specialties) trained.
Summary of bilateral results
The project contributed to the health system by improving access to services by the target populations. Also, through the development of Integrated Prevention and Patient Care services, new models have been developed for the effective treatment of TB patients, including latent tuberculosis, following WHO treatment recommendations.Also, the project had an impact on several lines of action:- increased universal access to rapid diagnostic methods and universal drug susceptibility testing- Patient support has been improved and adherence to treatment has been increased - created a good and safe model for infection control standards and requirements for healthcare facilities.- IEC public awareness campaigns contributed to changing the mentality towards tuberculosis, including latent TB / HIV.