multidrug resistant organisms l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Multidrug Resistant Organisms PowerPoint Presentation
Download Presentation
Multidrug Resistant Organisms

Loading in 2 Seconds...

play fullscreen
1 / 52

Multidrug Resistant Organisms - PowerPoint PPT Presentation


  • 297 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Multidrug Resistant Organisms' - kert


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.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
multidrug resistant organisms

Multidrug Resistant Organisms

Danae Bixler, MD, MPH

objectives
Objectives
  • Definitions
  • Explain:
    • Which MDROs are important and why
    • Reservoir for MDROs
    • Resistance to key antibiotics
    • Surveillance
    • Control measures
    • Challenges of outbreak investigation
slide3
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
siouxland region of iowa nebraska and south dakota n engl j med 2001 344 1427 1433
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
plan active surveillance n engl j med 2001 344 1427 1433
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
prevention collaborative http www cdc gov hai recoveryact stateresources collaborationprimer html
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
prevention collaborative http www cdc gov hai recoveryact stateresources collaborationprimer html11
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
surveillance http www cdc gov ncidod dhqp pdf ar mdroguideline2006 pdf
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
surveillance http www cdc gov ncidod dhqp pdf ar mdroguideline2006 pdf22
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
active surveillance cultures http www cdc gov ncidod dhqp pdf ar mdroguideline2006 pdf
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
infection control strategies evanston northwestern healthcare ann intern med 2008 148 409 418
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
infection control precautions http www cdc gov ncidod dhqp pdf ar mdroguideline2006 pdf
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
infection control precautions http www cdc gov ncidod dhqp pdf ar mdroguideline2006 pdf29
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
slide30
J ClinMicrobiol, 2005; 43:4961-4967.

Example – Outbreak of infection with a multiresistantKlebsiellapneumoniae strain associated with contaminated roll boards in operating rooms

case definition j clin microbiol 2005 43 4961 4967
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

slide34

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
slide35

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
slide36
Infect Control Hosp Epidemiol, 2009; 30:257-263.Example – nosocomial outbreak of infection with Pan-drug-resistant acinetobacterbaumannii in a tertiary care university hospital
case definition infect control hosp epidemiol 2009 30 257 263
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}.”
slide39
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
intensified mdro control measures http www cdc gov ncidod dhqp pdf ar mdroguideline2006 pdf
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
intensified mdro control measures http www cdc gov ncidod dhqp pdf ar mdroguideline2006 pdf41
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
slide42
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
bundled intervention infect control hosp epidemiol 2010 31 341 347
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
bundled intervention infect control hosp epidemiol 2010 31 341 34745
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
slide47
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

case definition am j infect control 2010 38 259
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.
infection control bundle am j infect control 2010 38 259
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
conclusions
Conclusions
  • MDROs can be controlled
    • Surveillance
    • Standard precautions (handwashing)
    • Contact precautions
    • Environmental cleaning
    • Monitoring of above
    • Interfacility collaboration and communication
slide52

Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care HospitalsInfect Control Hosp Epidemiol, 2008; 29(Suppl 1): S62

  • MRSA risk assessment
  • MRSA monitoring program
  • Hand hygiene guidelines
  • Contact precautions for MRSA-infected or colonized patients
  • Cleaning and disinfection of equipment and the enivronment
  • Educate
  • Laboratory alert system
  • Provide MRSA data and outcome measures to key stakeholders
  • Educate patients and families