MDRO (Multiple drug-resistant

organisms)

How they relate to patients in the healthcare setting

UT Southwestern University Hospitals: Infection Control Department

Multi-drug resistant organisms (MDRO’s) have increased in prevalence in US hospitals over the last three decades

These organisms have important implications for patient safety

Options for treating patients with these infections are often extremely limited

MDRO infections are associated with increased lengths of stay, costs, and mortality

Background

Methicillin Resistant Staphylococcus aureus (MRSA) was first isolated in the United States in 1968.

In the early 1990s, MRSA accounted for 20%-25% of Staphylococcus aureus isolates from hospitalized patients.

By 2003, MRSA accounted for >50% of S. aureus isolates from patients in ICUs.

A similar rise in prevalence has occurred with Vancomycin Resistant Enterococcus (VRE) . From 1990 to 1997, the prevalence of VRE in Enterococcus isolates from hospitalized patients increased from <1% to approximately 15% .

By 2003 VRE accounted for 28.5 % of Enterococcus isolates in ICUs.

History of MDRO’s

Methicillin-Resistant Staphylococcus aureus (MRSA)

Vancomycin-Resistant Enterococcus species (VRE) Multidrug-Resistant (MDR) Acinetobacter

species. Multidrug-Resistant (MDR) Klebsiella species,

Enterobacter species, and Escherichia coli.

Resistant Organisms include:

To be defined as an MDRO the organism must meet these criteria:

MRSA: S. aureus tests resistant to Oxacillin

VRE: Enterococcus species tests resistant to Vancomycin.

MDRO-Acinetobacter species: Resistant to all agents tested within at least 3 antimicrobial classes, including B-lactams, carbapenems, aminoglycosides and fluoroquinolones

Specific definitions

New Resistant Bacteria

Mutations

XX

Emergence of Antimicrobial Resistance

Susceptible Bacteria

Resistant Bacteria

Resistance Gene Transfer

Bacteria have evolved to evade antimicrobial drugs through chromosomal mutations & acquisition of resistance genes via conjugation, transposition, or transformation

Resistant StrainsRare

xx

Resistant Strains Dominant

Antimicrobial Exposure

xxxx

xx

xx

xx

Selection for antimicrobial-resistant Strains

Once resistant strains of bacteria are present in a population, exposure to antimicrobial drugs favors their survival.

S. aureus

Penicillin

[1950s]

Penicillin-resistant

S. aureus

Methicillin

[1970s]

Methicillin-resistant S. aureus (MRSA)

Vancomycin-resistant

enterococci (VRE)

Vancomycin

[1990s]

[1997]

Vancomycin

intermediate-resistantS. aureus (VISA)

[ ???? ]Vancomycin-

resistantS. aureus

Introduction of every new class of antimicrobial drug is followed by emergence of resistance

B-lactams: includes ampicillin/sulbactam, piperacillin/tazobactam, cefepime, ceftazidime

Carbapenems: includes imipenam, meropenem and doripenam

Aminoglycosides: includes amikacin, gentamycin, tobramycin

Fluoroquinolones: includes ciprofloxacin, levofloxacin

Drug classes:

Staphylococcus aureus◦ commonly found on skin, in eyes, upper respiratory track, mouth, and GU system◦ developed resistance to many Antibiotics including Methicillin (oxacillin) to create the

particular strain, MRSA

MRSA ◦ Is found anywhere Staphylococcus aureus is commonly found◦ may colonize the patient or cause active infections◦ is a public health concern because there are few drugs left to treat serious MRSA

infections. Vancomycin is the current drug of choice for serious infections. Other antimicrobial agents would include: Daptomycin and Linezolid.

A high percentage of wound infections are caused by MRSA.

Reservoirs for MRSA in the hospital include infected or colonized patients with HCW being the link for nosocomial spread of the infection. The main mode of transmission is via hands of HCW.

Other reservoirs include contaminated equipment and other items in the environment

Methicillin-Resistant Staphylococcus aureus (MRSA)Fact Sheet

The emergence of new epidemic strains of MRSA in the community, (CA-MRSA) among patients without established MRSA risk factors, may present new challenges to MRSA control in healthcare settings.

Historically, genetic analyses of MRSA isolated from patients in hospitals worldwide revealed a relatively small number of MRSA strains have the unique qualities to facilitate transmission from patient to patient.

To date, most MRSA strains isolated from patients with CA-MRSA

infections have been microbiologically distinct from those endemic in healthcare settings, suggesting some of these strains may have arisen de novo in the community via the acquisition of the mecA gene from Methicillin Susceptible Staph aureus.

CA-MRSA infection commonly presents as relatively minor skin and soft tissue infections, but severe invasive disease and mortalities have been described in children and adults.

Community-associated MRSA

When a patient is identified as having an infection or colonization with an MDRO:

◦ Place the patient in Contact Precautions

◦ Enter the isolation information into EPIC

◦ Staff will be alerted of isolation status upon subsequent admissions into the hospital

Monitoring of MDRO’s

Infection control monitors MDRO incidence and transmission and provides data monthly and quarterly to the units

Monitoring of MDRO’s

Removing Patients From Isolation Follow-up screenings MUST be negative:

Original site of infection +

Nasal if previously MRSA positive or

Rectal if previously VRE positive

Once the C. Diff positive patient is discharged, the isolation is removed automatically

Notify Infection Control to Remove Isolation Status from EPIC

Once MDROs are introduced into a healthcare setting, transmission and persistence of the resistant strain is determined by the:

◦ availability of vulnerable patients◦ selective pressure exerted by antimicrobial use.◦ the number of patients already colonized with an MDRO◦ the impact of implementation and adherence to prevention efforts

Patients vulnerable to colonization and infection include:

◦ those with severe disease◦ those with compromised host defenses from underlying medical conditions◦ recent surgery◦ indwelling medical devices (e.g., urinary catheters or endotracheal tubes)

Hospitalized patients have more risk factors than non-hospitalized patients, and have the highest infection rates.

There is ample epidemiologic evidence to suggest MDROs are carried from one person to another via the hands of HCW.

Hands are easily contaminated during the process of care-giving or from contact with environmental surfaces in close proximity to the patient.

Without adherence to published recommendations for hand hygiene and glove use HCW are more likely to transmit MDROs to patients.

Strategies to increase and monitor adherence are important components of MDRO control programs.

Hands are the culprits

Standard Precautions are a group of infection prevention practices which apply to all patients, regardless of suspected or confirmed infection status. They are in effect for all patients, all the time.

These include the use of: * Hand hygiene Gloves Gown Mask Eye protection, or face shield*depending on the anticipated exposure; and safe injection practices.

Equipment or items in the patient environment likely to have been contaminated with body fluids must be handled in a manner to prevent transmission of infectious agents.

While good hand hygiene remains the most important method to prevent the transmission of any organism on the hands of HCW, the addition of Contact Precautions can break the chain of infection by preventing the organisms from being carried from one room to another on inanimate objects (foamites).

Contact Precautions

Touching the PATIENT isn’t the only way to become contaminated with an MDRO!

Place green Contact Isolation sign on the room door

Any PERSON entering the room wears gloves and gown, no matter the reason for entering the room or for how long. This includes all staff and visitors.

Contact Isolation Precautions

Contact Isolation Precautions

Remove Personal Protective Equipment and perform hand hygiene BEFORE leaving the room.

Equipment from a Contact Precautions room should be disinfected before being used for the care of another patient .

Contact Isolation Precautions Sign

Contact

Sign Color Fluorescent Green

Type of Organism Isolated

MRSA

VRE

Clostridium difficile

Lice

Scabies

Procedure for Isolation

Wash Hands

Don Gown & Gloves BEFORE entering room

REMOVE Gown & Gloves BEFORE leaving room

Wash hands-- Soap & water only if C. diff, otherwise use alcohol foam when leaving room

C. difficile

Sign Color Red Stop Sign

Type of OrganismIsolated

Clostridium difficile

Procedure for Isolation

Wash Hands

Don Gown & Gloves BEFORE entering room

REMOVE Gown & Gloves BEFORE leaving room

Wash hands--SOAP & WATER ONLY when leaving roomStop Sign for Clostridium difficile

Contact Precautions+

Use ONLY soap & water to wash hands

Droplet

Sign Color Fluorescent Yellow/ Orange

Type of Organism Isolated

RSV

Influenza

Meningitis

Procedure for Isolation

Wash hands

Don Surgical Mask

REMOVE Mask when leaving room

Wash Hands after leaving room with soap & water or alcohol foam

Droplet Isolation Precautions Sign

Airborne

Sign Color Hot Pink

Type of Organism Isolated

AFB (Tuberculosis)

Measles

Chicken Pox

(Any staff who have NOT had measles or chicken pox or been vaccinated MAY NOT ENTER patient room.)

Procedure for Isolation

Don N95 mask BEFORE entering room

(Staff must have been fit tested by Occupational Health for appropriate size upon hire.)

Wash Hands

REMOVE Mask when leaving room

Wash Hands after leaving room with soap & water or alcohol foam

Airborne Isolation Precautions Sign

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

12 Contain your contagion

11 Isolate the pathogen

10 Stop treatment when cured

9 Know when to say “no” to Vanco

8 Treat infection, not colonization

7 Treat infection, not contamination

6 Access the experts

5 Use local data

4 Practice antimicrobial control

3 Target the pathogen

2 Get the catheters out

1 Vaccinate

Prevent Transmission

Use Antimicrobial

s Wisely

Diagnose & Treat

Effectively

Prevent Infections

Fact: Catheters and other invasive devices are the #1 exogenous cause of hospital-onset infections.

Actions:Use catheters only when essentialUse the correct catheterUse proper insertion & catheter-care

protocolsRemove catheters when not essential

Prevent Infection:Get the catheters out

Antimicrobial Resistance: Key Prevention Strategies

Optimize Use

PreventTransmission

PreventInfection

EffectiveDiagnosis& Treatment

Pathogen

Antimicrobial-Resistant Pathogen

Antimicrobial Resistance

Antimicrobial Use

Infection

Susceptible Pathogen

The Infection Control Team

Doramarie Arocha

Gwen Way

David Townson

Fact: A major cause of antimicrobial overuse is treatment of colonization.

Actions: Treat pneumonia, not the tracheal aspirate Treat bacteremia, not the catheter tip or

hub Treat urinary tract infection, not the

indwelling catheter

Use Antimicrobials Wisely

Treat infection, not colonization

Biofilm on Intravenous Catheter Connecter 24 hours after Insertion

Scanning Electron Micrograph

Fact: Vancomycin overuse promotes emergence, selection, and spread of resistant pathogens.

Actions:◦ Treat infection, not contaminants or colonization ◦ Fever in a patient with an intravenous catheter is

not a routine indication for vancomycin

Know when to say “no” to vanco

Fact: Failure to stop unnecessary antimicrobial treatment contributes to overuse and resistance.

Actions:When infection is curedWhen cultures are negative and

infection is unlikelyWhen infection is not diagnosed

Use Antimicrobials Wisely When to stop antimicrobial treatment

Fact:Patient-to-patient spread of pathogens can be prevented. Actions:Use standard infection control

precautions Contain infectious body fluids

(use approved airborne/droplet/contact isolation precautions)

When in doubt, consult infection control experts

Prevent Transmission

Fact:Healthcare personnel spread antimicrobial-resistant pathogens from patient-to-patient.

Prevent Transmission: Contain your contagion

Prevent Transmission: Contain your contagion Patients from Long Term Acute Care Facilities

(LTAC) have a higher incidence of being colonized with an MDRO

Isolate immediately upon arrival, no questions asked!

Follow MDRO Reduction Protocol

Notify Infection Control

Life Care◦ Dallas◦ Fort Worth◦ Plano

Vibra Specialty Hospital

Texas Specialty Hospital

Kindred Specialty Hospital◦ Multiple Locations in

Dallas and Fort Worth◦ Arlington◦ Mansfield

Gulf States LTAC Select Specialty

◦ DeSoto◦ Carrolton

Mesquite Specialty Hospital

Regency Hospital◦ Carrolton◦ Fort Worth

Plano Specialty Hospital

Baylor Specialty Hospital

Multi-Drug Resistant Organism Reduction (MDRO) Protocol: Known LTACs

Multi-Drug Resistant Organism (MDRO) Reduction Screening Protocol

How to Obtain a Nasal

Swab/Culture for MRSA Screen

Steps: Wash hands, apply clean gloves Peel open the BBL CultureSwab

sterile pouch at the point indicated by the diagram on the outside of the package.

Twist to remove the cap from the transport tube

Remove the swab Insert the swab approximated 2

cm (approximately ¾ inch) into the naris.

Rotate the swab against the anterior nasal mucosa for 3 seconds

Using the same swab, repeat for the other naris.

**If using swab with 2 heads, can use 1 swab for each naris.

Equipment: Clean disposable

gloves BBL CultureSwab

How to Obtain a Nasal Swab/Culture for MRSA Screen--

Continued

Push the end of the swab firmly to ensure that the swab is inserted into the end of the transport tube. Ensure that the swab tip is in contact with the moistened pledget.

Secure the transport tube cap.

Label the swab with the patient’s preprinted label in the presence of the patient, in the patient’s room

Remove and discard gloves

Place in biohazard bag Transport the labeled

specimen to the lab WITHIN 1 HOUR.

Label the swab with the patient’s preprinted label in the presence of the patient, in the patient’s room

Remove and discard gloves

Place in biohazard bag Transport the labeled

specimen to the lab WITHIN 1 HOUR.

Fact: Healthcare personnel spread antimicrobial-resistant pathogens from patient to patient.

Actions:Stay home when you are sick Contain your contagionKeep your hands cleanSet an example!

Prevent Transmission Break the chain of contagion