**1.12. Epidemiological surveillance: multimodal prevention program**

Epidemiological surveillance consists of the systematic collection, analysis and interpretation of data about a problem related to public health. The implementation of multimodal prevention programs must have the following elements: identification of problems, implementation plan, involvement of managers, record of compliance with objectives and, finally, the analysis of obstacles that may arise. An essential aspect of these programs is learning: the absence of adherence to the measures of the program due to lack of information or insufficient learning time should be avoided.

The antimicrobial stewardship programs bring together specialists in infectious diseases, clinical pharmacologists, clinical microbiologists, epidemiologists and other, sometimes also intensivists, all of them gathered for the purpose of an adequate prescription of antibiotics. But this is just one aspect of a complex problem like antibiotic resistance.

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


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

**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.

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

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**1.** Identify in each ICU at least one intensivist physician responsible for the control of antibiotics, with experience in surveillance and infection control and in the management of antibiotics. Systematically evaluate the use of antibiotics in ICUs and advise physicians responsible for patients with the intention of assessing reasons for prescription (indication), assessing choice and correct administration (dose, interval, duration) and possibility

**2.** Administer antibiotics empirically active against MRB only in infections with systemic response (severe sepsis, septic shock (SS)), and high suspicion of being MRB based on present risk factors and local epidemiology. In other cases, it is recommended to use lower spectrum antibiotics and/or wait for microbiology results to start antibiotics directed to MRB (carbapenems, colistin, tigecycline, glycopeptides, daptomycin, linezolid). In critical surgical patients with infection data but without sepsis/SS, the start of antibiotic treatment can be delayed until microbiological confirmation, without this implying an increase in

**3.** Designate a nurse as a project reference and responsible for the control of precautions directed to preventing the transmission of MRB. Ensure the effective implementation of the handwashing strategy, and dispose of an alcohol-based preparation dispenser in each bed.

**4.** Perform an active search for the presence of MRB in all patients at the time of admission to the ICU, and at least once a week throughout their stay. The type and number of samples will be chosen according to the local epidemiology, and at a minimum, they will include

*Acinetobacter baumannii* resistant to carbapenems.

The recommendations of the project are:

of withdrawal or adjustment.

mortality or stay in the ICU.

