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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.

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Multidrug Resistant Organisms

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  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

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