Multi-drug Resistant Organisms
(MDROs) in Healthcare Facilities
Gail Bennett RN, MSN, CIC
1
What we will cover:
General information
Specific MDROs
Methicillin Resistant Staph aureus (MRSA)
Vancomycin Resistant Enterococci (VRE)
Extended Spectrum Beta Lactamase Producers (ESBLs)
Klebsiella pneumoniae carbapenemase (KPC)
Resistant Acinetobacter baumannii
2
What we will cover:
Surveillance for MDROs
Control Measures
Isolation precautions
Hand hygiene
Environmental decontamination
Antimicrobial stewardship programs
3
Emergence of Antimicrobial
Resistance
Resistant Bacteria
Susceptible
Bacteria
Resistance Gene
Transfer
New Resistant Bacteria
4
Methicillin-Resistant
Staphylococcus aureus (MRSA)
MRSA emerged in the US soon after
Methicillin became commercially available in
the early 1960’s with the first case being
detected in 1968.
Increased prevalence in the ‘70s
5
2000: MRSA accounted for 53% of all S. aureus
clinical isolates from patients with nosocomial
infections acquired in US ICUs (NNIS)
2003: the percentage had increased to 59.5%
(NNIS)
6
The 1st identification
of MRSA in LTCFs
was in 1970 but it was
uncommon in LTC
until around 1985.
7
Methicillin-Resistant
Staphylococcus aureus (MRSA)
Resistant to methicillin, oxacillin, and nafcillin
Transmitted by direct and indirect contact
No more virulent than MSSA
Susceptible to common disinfectants
8
Risk Factors Contributing to MRSA
Colonization/Infection for all Facility
Types
Poor functional status
Conditions that cause skin breakdown
Presence of invasive devices
Prior antimicrobial therapy
History of colonization
9
Specific Risk Factors for MRSA
Colonization in LTCFs
Male gender Pressure ulcers
Urinary incontinence Antibiotic therapy
Fecal incontinence Hospitalized within
Presence of wounds the previous 6 months
10
What patients are more likely to
shed MRSA and need contact
precautions?
Heavy draining wound
Incontinent, diarrhea, colostomy
Cannot/will not contain secretions and excretions
Very poor hygiene
Difficult behaviors that may increase the risk of
transmission
Other
11
Treatment Regimens for MRSA
Infection
Vancomycin is the drug of choice
Disadvantages of Vancomycin
expensive
parenteral administration
ototoxicity
can potentiate nephrotoxicity of aminoglycosides
12
Treatment Regimens for MRSA
Infection
Linezolid (Zyvox) has been an alternative to
Vancomycin treatment of MRSA since 2000
Administered orally
13
Colonization/carrier state of
MRSA by Healthcare Workers
Do not routinely culture staff for colonization
with MRSA
It may be needed as part of an outbreak
investigation
HCW epidemiologic link to transmission
Before culturing,
Get expert consultation
Have an action plan in place! 14
Outbreak control
Contact precautions with observation for
compliance
Hand hygiene
If a decision has been made to culture staff for nasal
colonization: Mupirocin has been shown to be
somewhat effective.
15
Vancomycin-resistant
Staphylococcus aureus
1st case in US, June, 2002, Michigan; 2nd case -
September, 2002, Pennsylvania
Vancomycin resistant gene transferred from VRE in
same patient
To date, the US has had approximately 11 cases of
VRSA
CDC recommends private room, contact precautions
Reportable to your state and CDC
16
Vancomycin-resistant
Staphylococcus aureus
Excellent document: CDC. Investigation and
Control of Vancomycin-Intermediate and –
Resistant Staphylococcus aureus
(VISA/VRSA), September, 2006.
17
What about surveillance cultures to
find all patients/residents colonized
or infected with resistant
organisms?
Not routinely recommended for acute care,
LTCFs, or other healthcare facilities
May be needed in an outbreak
Must have an action plan before you start
culturing – I would suggest a consult with
the state epidemiology office first
18
Active surveillance cultures:
CDC says, “More research is needed to
determine the circumstances under which
ASC are most beneficial but their use should
be considered in some settings, especially if
other control measures have been
ineffective.”
CDC MDRO Guideline, 2006 19
However, hospitals have a relatively new
process for surveillance screening for
MRSA - Example:
All admits from LTCFs, jails, prisons
Anyone on dialysis
ICU/CCU admissions
CABG patients
Orthopedic patients: total joint replacements
Neuro: open back
Wounds/cellulitis
20
Are hospitals screening all
admissions for MRSA?
No, only a small % of their
admissions fall in their high risk
categories and get screened
21
So… do we isolate admissions to LTCFs
from the hospital who were culture
positive for MRSA in the nares?
No, not if that is the only site of MRSA
identified
We will be alert to the fact that the resident is
colonized and alert to any new healthcare
associated MRSA cases should they develop
22
Vancomycin-Resistant
Enterococcus (VRE)
Enterococcus faecalis
Enterococcus faecium
Contact Precautions - culture negative prior to
discontinuing precautions?
CDC now says we need to decide when to d/c
precautions but it may be prudent to have
negative culture(s) prior to d/c of isolation
23
Why contact precautions
for specific organisms?
Environmental contamination
24
The Inanimate Environment Can Facilitate
Transmission
X represents VRE culture positive sites
~ Contaminated surfaces increase cross-transmission ~
Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient
Environment. Hayden M, ICAAC, 2001, Chicago, IL.
25
Resistant Acinetobacter
baumannii
Aerobic gram-negative bacillus
High level of resistance
High numbers of A. baumannii infection
among our troops in Iraq
Causing outbreaks in healthcare facilities
Contact Precautions
See attached example
26
Acinetobacter baumannii: Example
microbiology report
Antimicrobial Interpretation Antimicrobial Interpretation
Polymyxin B S Ampicillin/ I
sulbactam
Ampicillin R Aztreonam R
Cephazolin R Ceftriaxone R
Trimethoprim/ R Cefepime R
Sulfa
Gentamicin R Ceftazidime R
Tobramycin R Piperacillin/ R
tazobactam
Levofloxacin R Imipenem R 27
Extended spectrum beta-lactamase
producers (ESBLs)
Gram negative organisms - Enterobacteriaceae
Excrete the enzyme beta-lactamase
Inactivates β-lactam (penicillin) type antibiotics
Resistance to β-lactams emerged several years ago and has
continued to rise
ESBLs
Klebsiella
E. coli
Serratia
others
Urine culture - Klebsiella
pneumoniae
Antimicrobial Interpretation Antimicrobial Interpretation
Ampicillin R Ciprofloxacin R
Ampicillin/ R Gentamicin S
sulbactam
Aztreonam R Imipenem S
Cephazolin R Nitrofurantoin R
Cefepime R Piperacillin/ I
tazobactam
Ceftazidime R Trimethoprim/ R
Sulfa
Ceftriaxone R
29
The Last Line of Defense
Fortunately, our most potent β-lactam class,
carbapenems, remained effective against
almost all Enterobacteriaceae.
Doripenem, Ertapenem, Imipenem, Meropenem
But… Antimicrobial resistance follows
antimicrobial use
30
Susceptibility Profile of KPC-Producing K. pneumoniae
Antimicrobial Interpretation Antimicrobial Interpretation
Amikacin I Chloramphenicol R
Amox/clav R Ciprofloxacin R
Ampicillin R Ertapenem R
Aztreonam R Gentamicin R
Cefazolin R Imipenem R
Cefpodoxime R Meropenem R
Cefotaxime R Pipercillin/Tazo R
Cetotetan R Tobramycin R
Cefoxitin R Trimeth/Sulfa R
Ceftazidime R Polymyxin B MIC >4μg/ml
Ceftriaxone R Colistin MIC >4μg/ml
Cefepime R Tigecycline S
31
Klebsiella pneumoniae
Carbapenemase (KPC)
Guideline
CDC - MMWR
March 20, 2009
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33
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Let’s talk about precautions for
MDROs…….
Contact Precautions
Protect HCWs from spreading microorganisms by direct
or indirect contact with resident or his environment
Prevent transmission within the facility
Contact precautions are the most common transmission-
based precaution used in the acute care setting, probably
droplet in LTCFs
Consider use with infections caused by MDROs (in
LTCFs we must make a case by case decision)
Consider the contaminated environment especially with C.
difficile and VRE
36
Contact Precautions for MDROs in Acute Care
Private room
Contact precautions
CDC MDRO guideline, 2006
37
Contact Precautions for MDROs in LTCFs
CDC tells LTCFs to consider:
the individual patient clinical situation
prevalence or incidence of MDROs in the facility
when deciding to implement or modify contact precautions in
addition to standard precautions for MDRO infected or colonized
patients.
Relatively healthy residents may need only standard precautions
while ill residents and those where secretions/excretions cannot
be contained may need contact precautions. CAUTION: some
MDROs require contact precautions even in LTCFs!
CDC MDRO guideline, 2006
38
Precautions in Ambulatory
Settings
CDC recommends standard precautions
Remember: we always have the option of
using gowns and gloves as needed even
without contact precautions!
Contact Precautions
Designed to reduce the risk of transmission of
microorganisms by direct or indirect contact
Direct contact
skin-to-skin contact
physical transfer (turning patients, bathing patients, other patient
care activities)
Indirect contact
Contaminated objects
Hands
Equipment
Clothing- potential exists for contaminated clothing to
transfer infectious agents to successive patients
New in the 2007 CDC isolation guidelines – cannot re-use same
isolation gown even on same patient
40
Contact Precautions
Patient placement
Private room OR
Cohorting (two or more patients/residents in same
room with same organism) OR
CDC recommends that LTCFs consider the
infectiousness and epidemiology of the organism to
determine rooming.
Consult internally with management and nurse consultant
if needed.
If roommate, should be someone low risk. 41
Who is a low risk
roommate?
No major wounds
No tubes (invasive
devices)
Not otherwise
immunocompromised
42
Contact Precautions
Hand hygiene
Gloves upon entering the room
Gowns upon entering the room
Patient/Resident socializing outside the room?
Consider:
Clean
Contained
Cooperative
Cognitive
Patient-care equipment: dedicate to single patient if possible; if
not – decontaminate prior to removal from the room
Purchase additional equipment if necessary
43
Contact Isolation
Pediculosis (lice)
Scabies
Ebola
Lassa or Marburg
Multi-drug Resistant
Organisms
44
Environmental Cleaning
Use an EPA registered, hospital grade germicidal agent
for environmental cleaning in clinical areas
May consider increased frequency of cleaning in heavily
soiled areas
Identify “high touch” areas throughout the building and
have them on scheduled cleaning
45
CDC Guideline for Hand Hygiene in Healthcare
Settings
(MMWR 2002, vol.51, no. RR16)
Hand Hygiene
CDC Guideline for Hand Hygiene
If washing with soap and water, at least 15 seconds
Soap and water for spore formers (C. diff), before eating, after
bathroom
Otherwise, alcohol rubs acceptable unless hands are soiled
No requirement to wash with soap and water after so may uses
of alcohol rub
Many facilities have mounted them in all patient/resident rooms
What about toxicity if swallowed?
Less abrasive to hands than soap and water
Wash after removing gloves
Fingernails - short
Does she work at your facility?
Antibiotic Review
F441: Because of increases in MDROs, review
of the use of antibiotics is a vital aspect of
the infection prevention and control program.
An area of increased surveyor focus- an area
where you need to assess if you are meeting
the surveyor guidance
What most likely exists currently in your program:
Comparison of prescribed antibiotics with available susceptibility reports
(charge nurse and infection preventionist)
Review of antibiotics prescribed to specific residents during regular
medication review by consulting pharmacist
What may be needed:
Antibiotic stewardship program in the facility (CDC recommendation –
2006 MDRO guideline)
Broader overview of antibiotic use in your facility with reporting to
quality assurance/infection control committee
Right drug - Right dosage - Right monitoring -
Feedback of data to MDs
Prescriber education
Standardized antimicrobial order forms
Formulary restrictions
Prior approval to start/continue
Pharmacy substitution or switch
Multidisciplinary drug utilization
evaluation (DUE)
Provider/unit performance feedback
Computerized decision support/on-line
ordering
Antimicrobial stewardship
CDC Fast Facts
Antibiotic overuse contributes to the growing problems of
Clostridium difficile infection and antibiotic resistance in
healthcare facilities.
Improving antibiotic use through stewardship
interventions and programs improves patient outcomes,
reduces antimicrobial resistance, and saves money.
Interventions to improve antibiotic use can be
implemented in any healthcare setting—from the smallest
to the largest.
Improving antibiotic use is a medication-safety and
patient-safety issue.
http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html
Prevention
IS
PRIMARY!
Protect patients…protect healthcare personnel…
promote quality healthcare!
55
References
CDC, Guideline for Isolation Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings 2007 (HICPAC), 2007; 1-219.
CDC, Management of Multidrug-Resistant Organisms in Healthcare
Settings, 2006 (HICPAC), 2006;1-74.
SHEA Guidelines for Preventing Nosocomial Transmission of Multidrug-
Resistant Strains of Staphylococcus aureus and Enterococcus. Infection
Prevention & Hospital Epidemiology, May 2003, pp. 362–386
CDC, Investigation and Control of VISA/VRSA. A guide for health
departments and infection control personnel. Updated: Sept. 2006
http://www.cdc.gov/ncidod/dhqp/pdf/ar/visa_vrsa_guide.pdf
Thank you!!
gailbennett@icpassociates.com
