The overall aim of this guideline is to improve the quality and safety of health care and the outcome of patients accessing health services, as well as the safety of health care workers, in the context of national and local action plans to prevent or reduce the spread of AMR. The emergence of CRE-CRAB-CRPsA and their rapid spread in several countries is considered to be one of the most alarming problems in the global health agenda related to AMR. Adoption of these guidelines in the form of national and local policies and their translation into practice at the facility level are therefore essential. Their integration within existing approaches to IPC and AMR surveillance and control is crucial.
National commitment to IPC and the implementation of IPC programmes, including the core components recommended in recently issued WHO guidelines (13) and their integration within the national action plans for AMR, are fundamental to the success of the CRE-CRAB-CRPsA guidelines. This is crucial for the achievement of strategic objective 3 of the AMR Global Action Plan adopted by all Member States at the World Health Assembly in 2015. It is key that national IPC programmes support the local programmes by several means, including setting national standards, fostering the training and recruitment of IPC staff, facilitating regular provision of IPC supplies, supporting the availability of adequate infrastructures and a clean environment, and the development of coordination activities with the local IPC team and other IPC-related programmes.
Guideline implementation
The successful implementation of the recommendations in these CRE-CRAB-CRPsA guidelines is dependent on a robust implementation strategy and a defined and appropriate process of adaptation and integration at the facility level, as well as inclusion in regional and national strategies. Implementation effectiveness will be influenced by existing health systems in each country, including available resources, the existing capacity and policies and a strong coordination mechanism at the national or sub-national level. The support of key stakeholders, partner agencies and organizations is also critical.
Specific details that need to be considered to adequately implement these CRE-CRAB-CRPsA guidelines are frequently addressed within these guidelines under “Remarks” and “Additional factors considered when formulating the recommendation” for each recommendation. The key points for each recommendation are summarized below in .
Recommendation resource implications and feasibility considerations.
Recommendation 1
The success of this recommendation clearly depends on the implementation of the IPC Core component 5 that is related to multimodal strategies as the best approach to practically implement an IPC intervention (13). A multimodal strategy indicates the “how” to implement IPC interventions and consists of several of elements or components (three or more; usually five) implemented in an integrated way with the aim of improving an outcome and changing behaviour. It often includes tools that facilitate the organization of the work and the execution of care processes and tasks, such as bundles and checklists or standard operating procedures. Multidisciplinary teams that are able to take into account and influence local conditions are key to develop and lead the implementation of multimodal strategies. The identification and involvement of champions or role models (that is, individuals who actively promote the components of the strategy and their associated evidence-based practices within an institution) has been shown to be very effective in several cases. Implementation of the multimodal strategy indicated in this recommendation requires the organizational coordination of activities within the facility and across teams and departments (for example, infection control, microbiology, infectious diseases, etc.) and strong support by senior management. Preventing or controlling the spread of CRE-CRAB-CRPsA should be considered as a priority patient safety issue. Thus, developing or strengthening a patient safety culture within the facility should be an essential focus of the multimodal strategies in response to AMR, including outbreak situations.
Recommendation 2
Improvement of hand hygiene compliance at the point of care can be achieved by implementing the WHO strategy and using the WHO toolkit or other similar multimodal strategies (http://www.who.int/infection-prevention/tools/handhygiene/en/). The key components of the WHO hand hygiene improvement strategy (77) are:
System change: ensuring that the necessary infrastructure is in place to allow health care workers to practice hand hygiene. This includes two key elements: (1) access to a safe, continuous water supply, soap and towels; and (2) readily accessible alcohol-based handrub at the point of care.
Training/education: providing regular training on the importance of hand hygiene to all health care workers, based on the “My 5 moments for hand hygiene” approach and the correct procedures for handrubbing and handwashing.
Evaluation and feedback: monitoring hand hygiene practices and infrastructure, together with related perceptions and knowledge among health care workers, while providing performance and results feedback to staff.
Reminders in the workplace: prompting and reminding health care workers about the importance of hand hygiene and the appropriate indications and procedures for its optimal performance.
Institutional safety climate: creating an environment and the perceptions that facilitate awareness raising about patient safety issues, while guaranteeing consideration of hand hygiene improvement as a high priority at all levels. This should include active participation at both the institutional and individual levels, an awareness of the individual and institutional capacity to change and improve (self-efficacy), and partnership with patients and patient organizations.
Recommendation 3
Sample collection for the surveillance of CRE colonization and reporting of results should be done as soon as possible after hospital admission or risk exposure. Some experts even believe that screening of high-risk patients should be undertaken in the emergency department when it is clear that they require hospital admission. However, even with prompt screening, there is an inevitable delay between sample collection and obtaining laboratory results. Thus, for patients considered to be at potentially high risk of CRE infection or colonization, pre-emptive patient isolation may need to be considered in some circumstances until surveillance results become available. The GDG considered such actions and information as an important patient safety issue. For this reason, the GDG believed that there was no need to obtain formal written patient consent for each screening culture, as long as a robust system was in place to routinely explain to patients the CRE prevention and control programme and its importance. However, it is important to recognize that such surveillance programmes may be associated with additional financial costs in terms of the microbiological cultures, the subsequent need for patient isolation and the equipment required. Nevertheless, these costs are universally considered to be worthwhile if they help to avoid a CRE outbreak as these types of outbreaks are well known to be very costly to contain. The GDG recognized the growing evidence of the role of genotyping and whole genome sequencing of CRE isolates and the value of integrating this information into the epidemiological investigation of outbreaks to help orient the consequent actions needed for their control. Nevertheless, some questions remain unanswered, including the criteria that accurately define when a patient is no longer colonized with CRE. Practical issues such as “how many negative surveillance cultures truly mean a patient is no longer colonized” remain uncertain, yet they can have substantive practical implications in terms of patient management both in outbreak and endemic settings. According to expert opinion, the GDG noted that at least two consequent negative cultures should be available in order to consider a patient no longer colonized; other protocols addressing surveillance guidance among other CRE prevention and control measures also exist (78).
Recommendations 4 and 5
The GDG recognized that an adequate and continuous availability of patient rooms and equipment/supplies are needed for the successful implementation of contact precautions and that the cost of this infrastructure and materials (including their disposal) was a critical consideration that requires careful planning, including resource availability. In some cases, it was noted that important details, such as what material is optimal for some equipment (for example, gowns), remain currently uncertain and require further research. Of note, the education and training of staff regarding these recommendations is critical for their successful and reliable implementation, as well as appropriate communication of their importance to patients.
Recommendations 6 and 7
Adequate routine cleaning of health care facilities is a fundamental pillar of good IPC, yet it may not always be undertaken as rigorously as it should be or as it is assumed to be. For CRE-CRAB-CRPsA control, good cleaning is critical. Nevertheless, the optimal cleaning agent has not yet been totally defined. The GDG noted that ensuring appropriate regular cleaning should not be considered as “enhanced” cleaning, but instead it should comprise the careful execution of standard cleaning protocols with special attention to the “patient zone”. Furthermore, the GDG recognized that the evidence demonstrating the value of environmental screening cultures related to their impact on improved environmental cleaning standards and activities was limited.
Recommendation 8
Monitoring, auditing and feedback is a fundamental aspect of any IPC intervention to demonstrate compliance and thus link it to the outcomes intended to be improved. These guidelines highlight the need to monitor the multimodal strategy (Recommendation 1) and the implementation of each specific recommendation. Standardized national or international tools should be used as much as possible (for example, hand hygiene compliance monitoring according to the method recommended by WHO; hand hygiene self-assessment framework: http://www.who.int/gpsc/country_work/hhsa_framework_October_2010.pdf?ua=1).
Although compliance with the recommendations should demonstrate the effect of these CRE-CRAB-CRPsA guidelines, the GDG recognized that some important topics that are likely to impact on their success may have not been discussed in this document and these need to be considered in the context of monitoring, auditing and feedback. In particular, the importance of good antimicrobial stewardship programmes to ensure appropriate antimicrobial prescribing to minimize the emergence of CRE-CRAB-CRPsA and the “selective pressure” that inappropriate prescribing can play in the problems associated with CRE-CRAB-CRPsA colonization and infection.
Guideline dissemination
The guidelines will be made available online and in print, together with all supplementary and additional information. They will also be accessible through the WHO library database and the web pages of the WHO IPC Global Unit, the WHO Antimicrobial Resistance Secretariat and the WHO Department of Service Delivery and Safety.
Active dissemination will then take place through a number of mechanisms including (not exclusively):
The Global IPC Network and the WHO Save Lives: Clean Your Hands and Safe Surgery Saves Lives global campaigns;
The WHO AMR coordination mechanisms, including the Newsletter;
WHO collaborating centres;
WHO stakeholders and collaborators (for example, other Service and Delivery Units, WASH unit, Emergency Response programme);
WHO regional and country offices, ministries of health, nongovernmental organizations (including civil society bodies);
Other United Nations agencies;
Professional associations;
Professional national and international societies.
Consideration will be given to the role of regional dissemination workshops and other international conferences and meetings, depending on successful resource mobilization.
The use of social media within the context of mobile health technologies will also be explored as a mechanism to supplement conventional dissemination approaches.
The guidelines will be translated into all official United Nations languages as soon as possible. Third-party translations into additional non-United Nations languages will be encouraged, complying with WHO guidance on translations. A short summary of the guidelines will be made available in print and online.
Technical support for the adaptation and implementation of the guidelines in countries will be provided at the request of ministries of health or WHO regional or country offices.
The IPC teams at all three levels of WHO will continue to work with all stakeholders and implementers to identify and assess the priorities, barriers and facilitators to guideline implementation. The team will support the efforts of stakeholders to develop guideline adaptation and implementation strategies tailored to the local context. Adaptation of the recommendations contained in the guideline is an important prerequisite to successful uptake and adoption to ensure the development of locally appropriate documents that are able to meet the specific needs of each country and its health service. However, modifications to the recommendations should be justified in an explicit and transparent manner.
Dissemination through the scientific literature is considered crucial for the successful uptake and adoption of the recommendations and WHO and members of the Systematic Reviews Expert Group aim to develop a number of papers for publication in peer-reviewed journals.
Evaluation of the recommendations
Implementation of these CRE-CRAB-CRPsA guidelines can be measured in a number of ways and an evaluation framework will be developed by the WHO IPC Global Unit in collaboration with stakeholders involved in the guideline development. Lessons learned from the dissemination and implementation of these guidelines will be reviewed in the development of the evaluation strategy. Mechanisms will be explored to track:
The number of countries that incorporate the CRE-CRAB-CRPsA guidelines in their facility and national IPC and AMR programmes. At present, no monitoring system exists that can collect this information in a comprehensive manner on a routine basis, but this will be actively explored.
The number of print copies and downloads from the WHO website as an indicator of interest in the guideline.
The number of requests for technical assistance from Member States.
Requests relating to adaptation and translations.
Review and update of the recommendations
Informed by the evaluation approach, WHO will establish a review period for these guidelines every 3–5 years.
