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  • MDRO (Multiple Drug-Resistant Organisms)How they relate to patients in the healthcare settingHendro WahjonoPPRA TeamDr Kariadi Hospital

  • MDROMDROMDROMDRO

  • A worldwide problem1Associated with increased morbidity, mortality, and hospital costs1Occurs in both hospitals and the community2Antimicrobial Resistance1. R. A. Kulkarni et al. Indian J Surg. 2005: Volume 67(6): 308-315.2 . Ben-David D, Rubenstein E. Curr Opin Infect Dis 2002;15:151-156.

  • WORLD HEALTH DAY 7TH April 2011Antimicrobial Resistance Dr.T.V.Rao MD*

    Dr.T.V.Rao MD

  • WHO World Health DayWorld Health Day is celebrated every year on 7 April, under the sponsorship of the World Health Organization (WHO).

    Dr.T.V.Rao MD*

    Dr.T.V.Rao MD

  • Antimicrobial Resistance Control Program(ARCP)/PPRA

    A SELF IMPROVEMENT PROGRAMin Indonesia2005

  • Konsep Dasar PPRADALINSKFTMIKROBIOLOGI KLINIKFARMASIPPRASMFSMFSMFSMFSMFSMFSMFSMF

  • Langkah Pengendalian Resistensi Antimikroba*

  • Pelayanan Mikrobiologi KlinikLaboratorium MikrobiologiIdentifikasi dan uji sensitivitasHasil pemeriksaan Konsultasi / Visitasi / Patient careBersama klinisi ikut terlibat merawat pasien infeksi.Turn Around Time report.Informasi Peta medan kumanPengelolaan data mikrobamenerbitkan informasi peta medan secara berkala*

  • *Strategic action

  • Laboratory Training for Field Epidemiologists

    Specimen Collection Clinically Relevant Microbiology Starts at the Source

  • Factors influencing internal quality Outside laboratoryWithin laboratorySamplehandlingPatientpreparationRequisitionSamplereceivingSampleCollectionSampleTransportPatientDoctorAnalysisReportsResults

  • Successful laboratory investigationsAdvance planningCollection of adequate and appropriate specimensSufficient documentation Biosafety and decontamination Correct packaging Rapid transport Choice of a laboratory that can accurately perform the testsTimely communication of results

  • Facilitate appropriate antimicrobial use through stewardship and infection control

  • MDRO(multidrug resistant organisms)Definition Microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent (e.g., MRSA,VRE), these pathogens are frequently resistant to most available antimicrobial agents

  • MDRO(multidrug resistant organisms Drug-resistant pathogens are a growing threat to all people, especially in healthcare settings.

  • ReservoirsInfected and colonized patients Contaminated environmental surfaces & patient care equipment

    Risk factors Colonization, age > 65, ICU admission, long hospital stay, frequent hospitalizations, invasive procedures, indwelling devices, underlying diseases, enteral feeding, LTCFs, antimicrobial exposure

    *MDROs Epidemiology

  • How are they spread?They can be spread by:Person to person via skin-to-skin contact with someone diagnosed with an MDROSharing a personal care itemThe environment contaminated with an MDRO (MDROs can live in the environment anywhere from 24 hours to a week, depending on the organism)

  • Enterococcus faecium (VRE)

    Staphylococcus aureus (MRSA)

    Clostridium difficile (C. Diff)

    Acinetobacter baumannii

    Pseudomonas aeruginosa

    Enterobacteriaceae (CRKP/CRE)

    *Important MDROs ESCAPE

  • Collateral damage of antibiotic therapy3rd generationcephalosporinsFluoroquinolonesC. difficileMDR PseudomonasC. difficile-lactam-resistantAcinetobacterVREESBL KlebsiellaSong, Jae-Hoon; The Changing Face of Polymicrobial Infections; presented at 24th ICC, Manila, June 4-, 2005

  • Resistance is not newIt is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body (Fleming, Nobel Prize Address)Alexander Fleming receiving his Nobel Prize in 1945

  • Why Concern over MDRO Infections?

    Cause serious, difficult-to-treat infections that can result in substantial morbidity, mortality, increased lengths of stay and excess cost

    Frequently preventable Usually acquired via transmission by:caregiver-to-patient, environment-to-patient, or patient-to-patientJudicious use of antimicrobials may decrease incidence of microorganisms developing antibiotic resistance

  • AGENT

    MODE OFTRANSMISSIONBreaking the Chain of Transmission

    Hand hygiene , standard precautions, transmission-basedprecautions (contact, droplet, airborne), aseptic technique,attention to the environment and patient care equipment, etc.SOURCE

    HOSTHAI infectionpreventionstrategies aretargeted atbreaking thechain oftransmission.

    Thesestrategiesmake up thefundamentalsof infectionprevention.

  • What Measures Can We Take to Prevent Transmission of MDROs?Hand Hygiene The Most Important Way to Prevent Transmission of Microorganisms and Infection

  • What Other Measures Can We Take to Prevent Transmission of MDROs?Isolation PrecautionsDevelop and utilize systems to identify patients with MDROs and notify Infection Preventionists, physicians and direct caregivers

    Place patients with a confirmed MDRO or history of an MDRO in single-patient rooms.

    Group patients with the same MDRO in designated areas if single-patient room unavailable

  • What Measures Can We Take to Prevent Transmission of MDROs?Environmental MeasuresClean and disinfect high-touch surfaces (eg bedrails, faucet handles) and equipment used in the patients environment that may be contaminated with pathogensDedicate noncritical medical items for use on patients known to be infected or colonized with an MDROInfected: organisms present, tissue invasion and symptoms are presentColonized: organisms present but no tissue invasion and patient is asymptomatic

  • *Rationale for Preventive strategies Antimicrobial stewardship Admitted to healthcare facilityAntimicrobials C Diff exposure & acquisition Colonized no symptoms Infected Symptomatic Optimizing Environmental cleaning and Hand Hygiene

  • Infection control monitors MDRO incidence and transmission and provides data monthly and quarterly to the unitsMonitoring of MDROs

  • Staph aureus (SA) resistant to betalactams.Nasal colonization general population 25-30 % for SA< 2% for MRSA

    Other colonization sites: rectum, axilla, throat, wounds Higher carriage among HCP, dialysis patients, diabetics, IV drug users

    *MRSA Epidemiology

  • Aerobic Gram positive cocci that inhabitant of GI tract and female genital tract

    25% all enterococcal isolates are VRE

    Resistance is commonly seen in isolates of E. faecium than E. faecalis

    Risk factors (Host, Healthcare facility, Antimicrobial exposure)

    *VancomycinResistant Enterococci (VRE) Epidemiology

  • Vancomycin Resistant Enterococcus (VRE)Enterococcus resides in our intestines asnormal flora. It concerns us when it developsresistance to Vancomycin.It has the potential to cause urinary tractinfection, bloodstream infection or surgicalsite infection.

  • Common sites of infection: urinary tract, surgical wound, blood stream Mortality rate is 2 times higher in VRE than VSE infections Survives on environment days weeks

    *VRE Epidemiology

  • Glucose fermenter (Enterobacteriaceae)Foodborne (Salmonella, Shigella)Healthcare-associated Enterobacter species (E. cloacae)Community and Healthcare-associated Klebsiella species (K. pneumoniae) Escherichia coli Nonglucose fermentersAcinetobacter baumannii Pseudomonas aeruginosa *Gram Negative MDROs

  • B lactamases resistant to B-lactams for decadesExtended spectrum B-lactamases (ESBL) resistant to 3rd generation cephalosporins, monobactams Usually nosocomial however 34% from patients with no healthcare contact Carbapenems the last line of defense for treatment

    *Development of Antimicrobial-Resistant Enterobacteriaceae

  • Carbapenem-Resistant Enterobacteriaceae (CRE) Resistance production of a carbapenemase also known as KP carbapenemase (KPC)Resides on transferable plasmids wide spread transmission Limits options for treatment (Polymyxins problems with nephrotoxicity)

    *Development of Antimicrobial-Resistant Enterobacteriaceae

  • Non-motile gram negative bacteria (32 species) Ubiquitous widely distributed in nature (soil, water, food, sewage) & the hospital environmentMDR-Ab is primarily a nosocomial pathogenLong survival time on inanimate surfaces extensive environmental contamination

    *MDR- Acinetobacter baumannii (Ab)Epidemiology

  • MDR- Ab Epidemiology Most common gram negative carried by skin of HCPMost common gram negative carried by skin of HCP

    Frequently colonizes tracheostomy site

    Chlorohexidine resistanceRespiratory care equipment Bed rails, Bedside tables,Mattresses, PillowsCurtains, door handlesKeyboardsFloor mops, sinks

    Air humidifiers Patient care itemsWound care proceduresEquipment carts,Infusion pumpsPatient monitors and X-ray board

    *Widespread environmental contamination

  • Aerobic gram-negative rods Ubiquitous in soil and water Moist environment (hydrophilic) (e.g. sink drains, vegetables, river water, etc.)P. aeruginosa is an opportunistic infection rarely colonize healthy individualAt Risk individuals: Immuno-compromisedBurn patients Patients on mechanical ventilationCystic fibrosis patients

    *MDR- Pseudomonas aeruginosa Epidemiology

  • Gram positive spore forming bacillus (rods) Obligate anaerobe Part of the GI Flora in1-3% of healthy adult70% of children < 12 monthsSome strains produce toxins A & B Toxins-producing strains cause C. diff Infection (CDI) CDI ranges from mild, moderate, to severe and even fatal illness

    *C. difficile : Epidemiology

  • Microbiologic surveillanceMolecular typingSamestrain?InvestigateAntibiotics?ReferYesNoYesNoOrganismsidentifiedControlStop

  • Dr.T.V.Rao MD*Document Antibiograms with WHONETWHONET is a free Windows-based database software developed for the management and analysis of microbiology laboratory data with a special focus on the analysis of antimicrobial susceptibility test results.

    Dr.T.V.Rao MD

  • NHSN Antimicrobial Use and Resistance (AUR) DataHealthcare FacilityCDCCDC FirewallRules for Security, Primary Data Entry, and Supplemental Data EntryInterface Engine/ Data RepositoryFacility FirewallParsingCodingValidatingStandardHL7 MessagesNHSN ApplicationWeb-based data entry and data access

  • NHSN Components and ModulesNHSNComponentPatient SafetyEvents Modules Device Associated Procedure Assoc. Medication Assoc.MDRO and CDADHigh Risk Inpatient Influenza VaccinationAntimicrobial Use and ResistanceMicrobiology susceptibility test resultsand/orAntimicrobial useforA minimum of 6 months per calendar year in specified hospital areas (e.g., Intensive Care Unit, Specialty Care Area).

  • AMP AmpicillinERY ErythromycinTCY TetracylineCHL ChloramphenicolGEN GentamicinCIP CiprofloxacinFEP CefepimeCTX CefotaximeCAZ CeftazidimeDKB DibekacinFOS FosfomycinMEM MeropenemMFX MoxifloxacinSXT Trimethoprim/SulfatmethoxazoleFOX Ce foxitin VAN VancomycinAMK Amikacin

    # PRESENTASE SENSITIVITAS TERHADAP ANTI BIOTIK DI BANGSAL ICU RSUP Dr. Karyadi ( BULAN JANUARI - JUNI 2010 )1. DARAHOrganismaJML ISOLATAMP %SERY %STCY %SCHL %SGEN %SCIP %SFEP %SCTX %SCAZ %SCSL %SDKB %SFOS %SMEM %SMFX %S FOX%SSXT %SVAN %SAMK %SStaphylococcus epidermidis260105033261333215037725775266010090Escherichia coli18205066565080403383668293163393Pseudomonas aeruginosa16005002633402014573360334001810053Staphylococcus aureus ss. aureus15506042751007810010010010086881009357100100Acinetobacter baumannii110251601000800802054057Enterobacter aerogenes60500164016006650501683Klebsiella pneumoniae ss. pneumonia505010008025401000100100600100Candida albicans2Streptococcus pneumoniae10010001001001001001001000

    NOTE : Staphylococcus epidermidis = MRSE = Positif =Fox Escherichia coli dan Klebsiella pneumoniae = ESBL = CTX + CAZ ( Resisten ) Pseudomonas, Acinetobacter baumannii dan Enterobacter aerogenes = MDRO * Berhati - hati Pemakaian Terapi Antibiotik Empirik Dengan Cephalosporin Generasi 3 * Telah Terjadi Infeksi Nosokomial

  • Use Antimicrobials Wisely Step 7: Treat infection, not contamination

    Fact: A major cause of antimicrobial overuse is treatment of contaminated cultures.

    Actions:use proper antisepsis for blood & other cultures culture the blood, not the skin or catheter hubuse proper methods to obtain & process all cultures

    Link to: CAP standards for specimen collection and management

  • Use Antimicrobials WiselyStep 8: Treat infection, not colonizationFact:A major cause of antimicrobial overuse is treatment of colonization.

    Actions:treat bacteremia, not the catheter tip or hubtreat pneumonia, not the tracheal aspiratetreat urinary tract infection, not the indwelling catheter Link to: IDSA guideline for evaluating fever in critically ill adults

  • MDRO BEDAH Januari-April 2013

    Chart1

    200000073000

    300010321000

    612130532000

    E.coli ESBL

    Klebsiella ESBL

    Proteus ESBL

    Acinetobacter MDRO2

    Pseudomonas MDRO

    Burkholderia MDRO

    Enterobacter MDRO

    MRSE

    MRSA

    VRE

    Klebsiella KPC

    E.coli CRE

    Sheet1

    E.coli ESBLKlebsiella ESBLProteus ESBLAcinetobacter MDRO2Pseudomonas MDROBurkholderia MDROEnterobacter MDROMRSEMRSAVREKlebsiella KPCE.coli CRE

    A1200000073000

    A2300010321000

    A3612130532000

    To resize chart data range, drag lower right corner of range.

  • Reliable answersLeast possible riskRapid diagnosisAppropriate treatmentMicrobiology LabClinicianCommunicationClinical MicrobiologistUnderstand the importance of appropriate antimicrobial for patient safety

  • Policy Deals withWe discuss on the Broad basisClinicians / Microbiologists / Pharmacists and Nurses do take part.Policies are framed on demands of the Clinical areas, depending on recent Infection surveillance data contributed from Microbiology Departments.

  • ANTIBIOTIC CHOICEExperienceRecall (top of mind)GuidelinesGeneral preferenceEmpiric TherapySAFETY DATADRUGPROPERTIESCOST OF TREATMENTSENSITIVITYPATTERNEASE OFADMINISTRATIONCOMPLIANCEEFFICACYPK/PDGENERALCONDITIONAVAILABILITY

  • Q. Whats the most expensive NEW antibiotics ?A. The one that doesnt work!!

  • Infectious Diseases Expert ResourcesInfectious Diseases SpecialistsOptimal Patient CareInfection Control ProfessionalsHealthcare EpidemiologistsClinical PharmacistsClinical PharmacologistsSurgical InfectionExpertsClinicalMicrobiologists

  • Thank You

    **Ref 3, p 151, C2, 1, L1-5

    Ref 3, p 153, C1, 2, L1-7

    Ref 3, p 151, C2, 1, L3-5Ref 4, p 166, C2, 4, L5-10, 5, L1-3, 5-10

    CMK

    Ref 1, p 3, C2, Bullets 2, 3Ref 2, p 185, C1, 1, L7-12; p 189, C2, 2, L4-7

    Ref 3, p 153, C1, 2, L1-7

    Ref 3, p 151, C2, 1, L3-5Ref 4, p 166, C2, 4, L5-10, 5, L1-3, 5-10

    Ref 1, p 3, C1, 4, L9-11ReferencesInfectious Diseases Society of America (IDSA). Bad bugs, no drugs: As antibiotic discovery stagnatesA public health crisis brews. Available at http://www.idsociety.org/pa/ISDA_Paper4_final_web.pdf. Accessed July 2005.Cosgrove SE, Kaye KS, Eliopoulous GM et al. Health and economic outcomes of the emergence of third-generation cephalosporin resistance in Enterobacter species. Arch Intern Med 2002;162:185190.Ben-David D, Rubenstein E. Appropriate use of antibiotics for respiratory infections: Review of recent statements. Curr Opin Infect Dis 2002;15:151156.Colodner R, Rock W, Chazan B et al. Risk factors for the development of extended-spectrum beta-lactamase-producing bacteria in nonhospitalized patients. Eur J Clin Microbiol Infect Dis 2004;23:163167.**2Various factors influence the quality of the laboratory results. These could be pre-analytic, analytic or post-analytic. Naturally, some of these factors are not within the scope of the laboratory. The cycle begins with the initiation of the request by the doctor for laboratory investigation (right or wrong choice of test), selection of proper test as related to the timing of the illness, proper completion of requisition form, adequate preparation of the patient for collecting representative clinical sample and proper collection, handling and transport of the sample to the laboratory. The analytical factors include quality of laboratory materials, equipment and performance of laboratory personnel. Post-analytical factors include transcriptional errors, incomplete reports and subjective interpretation.

    ****Patients acquire C diff at the HCF 1- contact with a healthcare worker with transient hand colonization, 2 contact with the contaminated environment, or (3) by direct contact with a patient with CDI. The rate of acquisition during hospitalization increases linearly with time and can be as high as 40%after 4 weeks of hospitalization*MRSA carriage varied substantially across 10 nursing homes. Overall point prevalence was 31% (range, 7%52%)Versus 6% in hospitals and 9%24% in intensive care units.

    Reservoirs: colonized and infected individuals (frequent contact with the healthcare system) Transmission: Person to person mainly through hands of HCP and direct contact with contaminated environmental services.

    Beta-Lactams: penicillins, cephalosporins, cephamycins, carbapenems, monobactams

    *Reservoirs: colonized and infected individuals (frequent contact with the healthcare system) Transmission: Person to person mainly through hands of HCP and direct contact with contaminated environmental services.

    Resistance develops due to acquisition of van gene clusters on mobile genetic elements that are transferable between enterococcal strains

    Host Related Risk Factors: VRE colonization , Enterococcal stool density, Immunodeficiency, Transplant recipient, Clostridium difficile diarrhea , Renal insufficiency, Severity of underlying illness Healthcare facilities: ICU Admission, Proximity to a patient with VRE, Length of hospitalization, Multiple unit stays, Enteral feedings (Total perienteral nutrition) Medications: Number, type, and duration of antibiotic therapy, Vancomycin use, 3rd Generation Cephalosporin utilization, Anti-anaerobic antibiotics (such as Clindamycin), Flouroquinolones (such as Ciprofloxacin)**Resistance mainly occurs in KP, reported in other Enterobecteriacea, few reports in Pseudomonas

    Reservoirs: colonized and infected individuals (frequent contact with the healthcare system) Transmission: Person to person mainly through hands of HCP and direct contact with contaminated environmental services.

    *Reservoirs: colonized and infected individuals (frequent contact with the healthcare system) Transmission: Person to person mainly through hands of HCP and direct contact with contaminated environmental services.

    In vitro survival time 329 days11 days survival on Formica, 12 days on stainless steelUp to 4 months on dry surfaces

    (Wagenvoort JHT, Joosten EJAJ. J Hosp Infect 2002;52:226-229)(Webster C et al. Infect Control Hosp Epidemiol 2000;21:246)(Wendt C et al. J Clin Microbiol 1997;35:1394-1397)32 species >2/3 of Acinetobacter infections are due to A. baumaniiThe bacteria colonize the pharynx intermittently in 7% of the general population and in addition can be isolated from sputum, urine, stool, and vaginal dischargesMDR-AB carriage and natural history have not been well studied Skin colonization are 25 to 40% among healthy individuals and up to 75% for hospitalized patients

    *The bacteria colonize the pharynx intermittently in 7% of the general population and in addition can be isolated from sputum, urine, stool, and vaginal discharges

    MDR-AB carriage and natural history have not been well studied

    Skin colonization are 25 to 40% among healthy individuals and up to 75% for hospitalized patients

    *G positive means (Dark blue when use gram stainObligate anaerobes does not require O2 to survive Toxins are required to cause disease. A is the major toxins B can also cause the same illness as A CDI used to be called CDAD

    *** Outbreak Investigation: First, detect problem by microbiologic surveillance. Then, identify organisms and use molecular typing to determine whether or not we have the same strain. Next, if it is determined that the organisms are largely the same strain (which suggests patient to patient transmission), we investigate and control this using traditional infection control measures an emphasis on contact precautions, using gloves and gowns for contact with the immediate patient environment as well as an emphasis on hand-washing and antisepsis.****Optimizing skin antisepsis is the first critical step in obtaining blood samples for culture.Proper specimen collection and management is key to preventing contaminated cultures. *Clinical criteria and additional laboratory data can help distinguish infection from colonization.Improving the specificity of diagnostic criteria for infection can help reduce unnecessary antimicrobial use. ***Infectious diseases specialists are one important resource for providing input, but many other professionals also contribute to optimal care for patients with infectionsLike all patient safety endeavors, multidisciplinary collaboration is key! *