1 / 52

Multidrug Resistant Organisms

Multidrug Resistant Organisms. Danae Bixler, MD, MPH. Objectives. Definitions Explain: Which MDROs are important and why Reservoir for MDROs Resistance to key antibiotics Surveillance Control measures Challenges of outbreak investigation.

kert
Download Presentation

Multidrug Resistant Organisms

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Multidrug Resistant Organisms Danae Bixler, MD, MPH

  2. Objectives • Definitions • Explain: • Which MDROs are important and why • Reservoir for MDROs • Resistance to key antibiotics • Surveillance • Control measures • Challenges of outbreak investigation

  3. Public Health Significance of Multi-Drug Resistance http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf • Increased: • Cost • Length of stay • Admissions to ICU • Surgical procedures • Morbidity • Mortality

  4. N Engl J Med, 2001; 344:1427-1433 Example – control of a vancomycin-resistant enterococcus in health care facilities in a region

  5. Siouxland region of Iowa, Nebraska and South Dakota N Engl J Med, 2001; 344:1427-1433 • 4 acute care facilities • 28 long term care facilities • Population 135,000 • December 1996 - April 1997 - isolates of VRE increased from 0 to 63 • Meeting of health care facilities, District Health Department, state health departments, Indian Health Service

  6. Plan: Active Surveillance N Engl J Med, 2001; 344:1427-1433 Acute Care Facilities Long Term Care Facilities Patients admitted from acute care with unknown VRE status (pre-emptive contact precautions) Patients: hospitalized longer than 72 hours; on dialysis, with cancer, transplant or in ICU; who have had prolonged treatment with antimicrobial agents; or with invasive devices • Patients transferred from acute care facilities outside the community • Patients: • hospitalized longer than 72 hours; • on dialysis, with cancer, transplant or in ICU; • who have had prolonged treatment with antimicrobial agents; or • with invasive devices

  7. Plan: Infection ControlN Engl J Med, 2001; 344:1427-1433

  8. Plan: Infection ControlN Engl J Med, 2001; 344:1427-1433

  9. Colonization Rates, 1997 – 1999, Siouxland RegionN Engl J Med, 2001; 344:1427-1433

  10. Prevention Collaborative http://www.cdc.gov/hai/recoveryact/stateResources/collaborationPrimer.html • Coordinator • Multidisciplinary advisory group • Healthcare facility participation • Written commitment / Letters of support • Prevention strategies • Science-based • Feasible

  11. Prevention Collaborative http://www.cdc.gov/hai/recoveryact/stateResources/collaborationPrimer.html • Meetings • Agree on goals • Share learning, communication and feedback • Measurement • Select a measurement system (e.g., NHSN) • Facility commitment to participate • Regular feedback • Ongoing communication

  12. MDROs Reported to NHSN, 2006-2007Infect Control Hosp Epidemiol, 2008; 29:996-1011

  13. MDROs Reported to NHSN, 2006-2007Infect Control Hosp Epidemiol, 2008; 29:996-1011

  14. Reservoirs for MDROs

  15. Resistance 101Staphylococcus aureus

  16. Resistance 101Enterococcus

  17. Resistance 101Gram Negative Bacilli

  18. Types of Infections Caused by MDROsGram (+) CocciMandell, 7th Edition

  19. Types of Infections Caused by MDROsGram (+) Cocci (2)Mandell, 7th Edition

  20. Types of Infections Caused by MDROsGram (-) BacilliMandell, 7th Edition

  21. Surveillancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdfSurveillancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf • Routine clinical cultures (antibiograms) • Detect emergence of new MDROs • Facility- or unit- specific summary antimicrobial susceptibility reports • Monitor for changes • MDRO incidence (new isolates per 1000 patient days or per month) • Monitor trends / evaluate impact of prevention • Does not distinguish colonization from infection

  22. Surveillancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdfSurveillancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf • MDRO infection rates • Requires clinical data • Helpful in defining clinical impact • Molecular typing • Confirm clonal transmission • Evaluate interventions in facility

  23. Active Surveillance Cultureshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf • Prospective identification of colonized persons • Coupled with intervention can reduce transmission • Resource intensive • Methods • MRSA: nares > perirectal and wound • VRE: stool, rectal or perirectal • MDR-GNB: peri-rectal or rectal alone or in combination with oropharyngeal, endotracheal, inguinal, or wound

  24. Ann Intern Med, 2008; 148:409-418. Example – universal surveillance for MRSA in 3 affiliated hospitals

  25. Infection Control StrategiesEvanston Northwestern Healthcare Ann Intern Med, 2008; 148:409-418 • 3 hospitals • 40,000 annual admissions • 450 staff physicians • Contact isolation for MRSA-colonized persons • Private room or cohort • Gowns and gloves for all room entries • Dedicated equipment, e.g., stethoscopes

  26. Study Design Ann Intern Med, 2008; 148:409-418

  27. Ann Intern Med, 2008; 148:409-418

  28. Infection Control Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf • Standard precautions • Masks for: • Splash-generating procedures • Patients with open tracheostomies • Circumstances when there is evidence of transmission from heavily colonized sources (e.g., burns) • Contact precautions • All patients with infections or previously identified as colonized • Patients with ability to perform hand hygiene and without draining wounds, diarrhea, uncontrolled secretions: establish ranges of permitted ambulation, socialization and use of common areas based on risk … • Cohorting, in order of preference: • Single patient room • Cohort with patient with same MDRO • Cohort with low-risk patient

  29. Infection Control Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf • Environmental measures • Increased cleaning of: • Items in close proximity to patient, e.g., bed rails, over-bed tables • Frequently touched surfaces • Monitoring • Decolonization

  30. J ClinMicrobiol, 2005; 43:4961-4967. Example – Outbreak of infection with a multiresistantKlebsiellapneumoniae strain associated with contaminated roll boards in operating rooms

  31. Case definitionJ Clin Microbiol, 2005; 43:4961-4967. • “Cases were defined as patients who were admitted to the ICU for > 24 h in November 2000 and who were positive for MRKP* by culture of specimens taken between 1 November 2000 and 31 December 2000. • Samples for culture were taken from specific infection sites or for surveillance, and samples from both colonized and infected patient were included.” *resistant to trimethoprim-sulfamethoxazole and aminoglycosides; ESBL positive

  32. Description of CasesJ Clin Microbiol, 2005; 43:4961-4967.

  33. Genotyping of Isolates from Patients and OR RollboardsJ ClinMicrobiol, 2005; 43:4961-4967.

  34. Disinfectants for non-critical itemsPractical Healthcare Epidemiology, 3rd Edition; http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf • Chlorine-based products • Sporicidal • Corrosive • Respiratory irritant • Inactivation by organic matter • Phenolics • Bactericidal, fungicidal, virucidal, tuberculocidal • Tissue irritant • Hyperbilirubinemia in neonatal nursery

  35. Disinfectants for non-critical itemsPractical Healthcare Epidemiology, 3rd Edition; http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf • H2O2 • Bactericidal, fungicidal, virucidal, sporicidal • Chemical irritant • Quaternary ammonium compounds • Bactericidal, fungicidal, virucidal against lipophilic (enveloped) viruses • Not sporicidal, tuberculocidal or active against hydrophilic viruses. • Inactivated by water hardness and cotton • 70-90% alcohol • Virucidal, tuberculocidal • Lack sporicidal action and cannot penetrate protein-rich materials • Damage some surfaces after repeated use

  36. Infect Control Hosp Epidemiol, 2009; 30:257-263. Example – nosocomial outbreak of infection with Pan-drug-resistant acinetobacterbaumannii in a tertiary care university hospital

  37. Case DefinitionInfect Control Hosp Epidemiol, 2009; 30:257-263. • “A case patient was defined as any inpatient who had a pan-drug-resistant A baumannii isolate recovered from a clinical or surveillance sample obtained at least 48 hours after ICU admission {from April 9, 2002 to March 9, 2003}.”

  38. Infect Control Hosp Epidemiol, 2009; 30:257-263.

  39. Interventions to Control Pan-Drug-Resistant Acinetobacterbaumannii Infect Control Hosp Epidemiol, 2009; 30:257-263. • Environmental decontamination • Environmental survey • Revision of cleaning protocols • Active surveillance for PDRAB • Rectal and pharyngeal swabs of roommates • Educational programs for the staff • Display of posters illustrating isolation measures and antimicrobial use recommendations

  40. Intensified MDRO Control Measureshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf • Obtain consultation • Evaluate staffing and resources • Educate • Judicious antimicrobial use • Active surveillance and pre-emptive contact isolation • Contact precautions for all colonized or infected patients

  41. Intensified MDRO Control Measureshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf • Stop new admissions to the unit or facility if transmission continues • Dedicated use of non-critical equipment • Training for environmental staff • Monitor cleaning • Vacate units for intensive cleaning when previous efforts fail • Decolonization for MRSA (only) with expert consultation

  42. Infect Control Hosp Epidemiol, 2010; 31: 341-347. Example – Successful control of an outbreak of Carbapenemase-producing Klebsiellapneumoniae in a long term acute care hospital

  43. Infect Control Hosp Epidemiol, 2010; 31: 341-347.

  44. Bundled InterventionInfect Control Hosp Epidemiol, 2010; 31: 341-347 • Daily chlorhexidine baths for all patients • 2% chlorhexidine from the jawline downward • Observational study of terminal cleaning • Bedrails, IV pumps, poles, respiratory tubing, etc. not cleaned at all • Environmental cleaning • Cleaning personnel - clean all surfaces • Respiratory therapy - nightly cleaning of all mechanical ventilator surfaces and O2 valves • Nursing – disinfect all shared objects • All bedside curtains replaced

  45. Bundled InterventionInfect Control Hosp Epidemiol, 2010; 31: 341-347 • Surveillance cultures on new admissions • Surveillance rectal swabs on all patients • Isolation and contact precautions • High risk patients placed in pre-emptive contact isolation (CI) on admission until documented (-) • (+) patients placed in CI • Personnel education • Environmental cultures to monitor cleaning

  46. Infect Control Hosp Epidemiol, 2010; 31: 341-347.

  47. Am J Infect Control, 2010; 38: 259. Example – Management of a multidrug-resistant AcinetobacterBaumannii outbreak in an intensive care unit using novel environmental disinfection: a 38 month report

  48. Case Definition Am J Infect Control, 2010; 38: 259 • Identification of A baumannii recovered from a patient with an apparent clinical infection due to this pathogen after more than 2 days in the ICU.

  49. Infection Control Bundle Am J Infect Control, 2010; 38: 259 • Addition of a new hand hygiene product – alcohol-based hand gel in each patient room • Hand hygiene training • Observations of environmental cleaning • Contact isolation of all MDR A baumannii patients • Environmental culturing • A baumannii isolated from drain

  50. Am J Infect Control, 2010; 38: 259

More Related