**2. Resistance Zero (RZ) project**

The Spanish Society of Intensive Care (SEMICYUC) has developed several projects with the aim of reducing infectious events (nosocomial infections): Bacteremia Zero (BZ) (catheter-related bacteremia) and Pneumonia Zero (NZ) (pneumonia associated with mechanical ventilation). After the implementation of these projects, a sustained decrease in the rate of such infections, and globally nosocomial infections has been achieved (**Figure 1**). It has been described that, surprisingly, the rate of pneumonia associated with mechanical ventilation began to decrease with the start of the BZ Project.

The last project carried out is Resistance Zero (RZ). Its objectives are:


The aim of the project is to minimize the three factors that influence the appearance of MRB in critical patients: the adequate prescription of antibiotics, the early detection of MRB and Current Status of Colonization and Infection by Multiresistant Bacteria in the Spanish Intensive… http://dx.doi.org/10.5772/intechopen.78236 45

**Figure 1.** Decrease of acquired in ICU infection rate (patients with acquired in ICU infections for every 100 patients admitted to the ICU) during the different zero projects. Start of BZ 2009: Start of NZ 2011; start of Resistance Zero 2014.

the prevention of its spread/cross colonization, and the elimination of reservoirs. The MRBs in follow-up are: MRSA, VRE, Enterobacteria resistant to third generation cephalosporins, especially the ESBL producers, and those resistant to carbapenems, especially the carbapenemase producers; *P. aeruginosa* resistant to> = 3 families of antibiotics including: carbapenems, cephalosporins, piperaziline/tazobactam, fluoroquinolones, aminoglycosides, colistin; and *Acinetobacter baumannii* resistant to carbapenems.

The recommendations of the project are:

The 12 steps described by the CDC to prevent antibiotic resistance are the following:

• analyze the sensitivity of the germ and to adapt the treatment to the pathogen;

• stop antibiotic treatment if patient has healed (propose the reduction of antibiotic treat-

The Spanish Society of Intensive Care (SEMICYUC) has developed several projects with the aim of reducing infectious events (nosocomial infections): Bacteremia Zero (BZ) (catheter-related bacteremia) and Pneumonia Zero (NZ) (pneumonia associated with mechanical ventilation). After the implementation of these projects, a sustained decrease in the rate of such infections, and globally nosocomial infections has been achieved (**Figure 1**). It has been described that, surprisingly, the rate of pneumonia associated with mechanical ventilation began to decrease

• Primary: reduce by 20% the appearance of one or more MRBs of Nosocomial origin that are

• Secondary: describe the MRB map in spanish ICUs, differentiating those identified at the time of admission to the ICU and those that appear after 48 h of stay; promote and reinforce the safety culture in them; and create a network of UCIs, through the autonomous com-

The aim of the project is to minimize the three factors that influence the appearance of MRB in critical patients: the adequate prescription of antibiotics, the early detection of MRB and

• prevention of the infection:

44 Current Topics in Intensive Care Medicine

• removal the catheters (as soon as possible);

• effective diagnosis and treatment of the infection:

• treat the infection, not the colonization or the contamination;

ment according to the clinical situation of the patient);

The last project carried out is Resistance Zero (RZ). Its objectives are:

munities, that apply safe practices of demonstrated effectiveness.

• vaccine administration;

• discuss with experts;

• antibiotic control;

• appropriate use of antimicrobials:

• know how to refuse vancomycin;

• prevention of the transmission:

• break the chain of infection.

with the start of the BZ Project.

identified during their admission in ICU;

**2. Resistance Zero (RZ) project**

• isolate the pathogen;

• knowledge of local microbiological data;


nasal, rectal and oropharyngeal swabs (tracheal aspirate in intubated patients); in addition, you can take other samples to control possible reservoirs (infections, skin ulcers, etc). The samples will be processed to identify the MRBs recommended by the local epidemiology, according to Microbiology and the infection control teams of each hospital.

As additional recommendations, hand hygiene is very important, with the use of hydroalcoholic solution by health personnel before and after patient care. It is the most effective measure for the transmission of germs. Its purpose is to prevent the transmission of microorganisms in a bidirectional way between professionals and patients, besides protecting the care environment of pathogenic microorganisms. The priority method to perform hand hygiene in the absence of organic matter or visible dirt is the friction with alcohol-based products. They will not be used in case of contact with patients/surfaces contaminated with spores (C difficile). Gloves should be worn in several situations: when handling blood or body fluids, mucous membranes or non-intact skin, when transporting or touching surfaces stained with blood, liquids or body fluids, or performing any procedure of blood extraction or parenteral treatment. They must be changed if they are broken or contaminated, between one patient and another, and between procedures in the same patient. The misuse of gloves increases the

Current Status of Colonization and Infection by Multiresistant Bacteria in the Spanish Intensive…

http://dx.doi.org/10.5772/intechopen.78236

47

• Rates of patients with one or more BMR acquired in ICU: number of patients admitted to the ICU with 1 or more MRBs identified after 48 h of admission (and up to 48 h after discharge from the ICU) for 1000 days of stay in ICU, or by 100 patients admitted. MRBs are evaluated in clinical samples (infections or colonizations) and in surveillance samples, but not in

• Rate of days free of antibiotics: number of days—patient who does not receive systemic antibiotics for 1000 days of ICU stay. All systemic antibiotics are included regardless of the

• Rate of antibiotic use in infections acquired in ICU: number of days - patient with systemic

The project is complex and flexible, and adapts to the reality of each hospital. It is also contemplated to apply an integral security plan that seeks to promote and strengthen the safety culture in the daily work in the ICUs. Health professionals who provide critical care to the critically ill patients must be aware of the security risks of our units. The culture in general safety of the unit must be evaluated. We must work proactively on the potential risks of critical patient care, and propose recommendations based on daily practice that tries to minimize them. The notification of errors should be encouraged, and a goal of improvement should be proposed over time, with follow-up of proposed measures to achieve it. We have developed daily checklist tools that assess the safety of the patient on a daily basis in the different spheres of their management, and even a list of daily objectives—need of tubes/catheters, assessing whether parenteral medication can be suspended or passed to oral route, possibility of discharge from the ICU, and so on.

This project has preceded and promoted the creation of a new National System for the Surveillance of Infection Related to Health Care in Spain, in agreement with the Ministry of Health.

Data on infections associated with healthcare acquired in ICU are assessed by the ECDC. Recent data (2015) [1, 2] show that 8.3% of patients who remain in the ICU for more than

antibiotic treatment for infections acquired in ICU, for 1000 days of ICU stay.

risk of pathogen transmission, and its use never substitutes for hand hygiene.

The indicators used in the RZ project are:

environmental samples.

reason for their use.

**3. European data. ECDC**


As additional recommendations, hand hygiene is very important, with the use of hydroalcoholic solution by health personnel before and after patient care. It is the most effective measure for the transmission of germs. Its purpose is to prevent the transmission of microorganisms in a bidirectional way between professionals and patients, besides protecting the care environment of pathogenic microorganisms. The priority method to perform hand hygiene in the absence of organic matter or visible dirt is the friction with alcohol-based products. They will not be used in case of contact with patients/surfaces contaminated with spores (C difficile). Gloves should be worn in several situations: when handling blood or body fluids, mucous membranes or non-intact skin, when transporting or touching surfaces stained with blood, liquids or body fluids, or performing any procedure of blood extraction or parenteral treatment. They must be changed if they are broken or contaminated, between one patient and another, and between procedures in the same patient. The misuse of gloves increases the risk of pathogen transmission, and its use never substitutes for hand hygiene.

The indicators used in the RZ project are:

nasal, rectal and oropharyngeal swabs (tracheal aspirate in intubated patients); in addition, you can take other samples to control possible reservoirs (infections, skin ulcers, etc). The samples will be processed to identify the MRBs recommended by the local epidemiol-

**5.** At the time of admission of each patient in ICU, a checklist that includes several items (hospital admission>5 days in the previous 3 months, institutionalized-prison, social health centers, nursing homes-, colonized or infected by MRB) will be completed., antibiotics> = 7 days in the previous month -especially with third and fourth generation cephalosoporins, quinolones and carbapenemics-, chronic renal failure undergoing hemodialysis or chronic ambulatory peritoneal dialysis, and chronic pathology with a high incidence of MRB colonization/infection-cystic fibrosis, bronchiectasis, chronic ulcers-) with the objective of identifying those patients with high risk of being carriers of MRB. In patients with one or more risk factors, preventive contact precautions will be

**6.** Control compliance with the different types of precautions that should be applied: standard, or based on transmission mechanisms (isolation). The precautions will vary according to the identified MRB and its transmission mechanism (drops, air, and contact). They are mandatory standards for all health personnel and for the families of the patient. Nursing empowerment must be recognized to control strict compliance. The presence of necessary material for its application must also be facilitated. Contact isolation should be practiced with the use of a coat and gloves before contacting the patient, and removing

**7.** Have an updated protocol for daily and terminal cleaning of rooms occupied by patients with MRB. Several aspects must be agreed with the cleaning and Preventive Medicine teams of the hospital: the cleaning method (method, frequency, products, etc.) according

**8.** Elaborate a document for cleaning the clinical material and scanning devices in the ICU, commonly used in hospitalized patients, assessing whether cleaning, disinfection or sterilization is necessary. The importance of cleaning the sanitary material (fondendoscopes, fiberoptic bronchoscopes, etc.) and nonsanitary (computer keyboards, landline and mobile phones, keys, etc.) usually used in the ICU should be made aware. It is the

**9.** Include products containing chlorhexidine (4% soaps or other products impregnated with 2%) in the daily hygiene of patients colonized/infected with MRB, in addition to the obvious

**10.** Given the suspicion of an epidemic outbreak, it is recommended to typify at a molecular level the causative microorganism to know the clone responsible for the outbreak and its traceability. Studies of outbreaks based on phenotypic characteristics (antigenic, metabolic or antibiotic resistance properties) are insufficient to establish conclusive differences or similarities between microorganisms. The molecular typing allows us to know the transmission mechanisms of the pathogen to establish measures that prevent its dissemination. The centers that do not have means can submit the microbiological samples to the Resistance Vigilance Program of the National Microbiology Center of the Carlos III Health Institute (Madrid).

responsibility of each worker to clean and disinfect appliances for personal use.

ogy, according to Microbiology and the infection control teams of each hospital.

applied, and surveillance culture samples will be collected.

46 Current Topics in Intensive Care Medicine

them before leaving the patient's environment (for a single use).

need for cleaning to eliminate organic waste.

to the type of surface and the fixed structures present, including the beds.


The project is complex and flexible, and adapts to the reality of each hospital. It is also contemplated to apply an integral security plan that seeks to promote and strengthen the safety culture in the daily work in the ICUs. Health professionals who provide critical care to the critically ill patients must be aware of the security risks of our units. The culture in general safety of the unit must be evaluated. We must work proactively on the potential risks of critical patient care, and propose recommendations based on daily practice that tries to minimize them. The notification of errors should be encouraged, and a goal of improvement should be proposed over time, with follow-up of proposed measures to achieve it. We have developed daily checklist tools that assess the safety of the patient on a daily basis in the different spheres of their management, and even a list of daily objectives—need of tubes/catheters, assessing whether parenteral medication can be suspended or passed to oral route, possibility of discharge from the ICU, and so on.

This project has preceded and promoted the creation of a new National System for the Surveillance of Infection Related to Health Care in Spain, in agreement with the Ministry of Health.
