The Alan D. Junkins, PhD, D(ABMM) of Multi- Drug- Resistant Organisms Sponsored by an educational...

The

Alan D. Junkins, PhD, D(ABMM)

of Multi-Drug-

Resistant Organisms

Sponsored by an educational grant from

Louisville, KY

You know that Pseudomonas aeruginosa from Mr. Jones in 5F? Is

that an MDRO?

Why do you want to know?

Why are you asking me?

How should I know?


• Your own internal monitoring– “We’ve had a 35% increase in MRSA isolates this

year.”• For infection control purposes– “All patients with MDR GNB are placed in contact

precautions.”• Reporting to authorities– “We have to report all MDROs to the state.”




precautions.”• Reporting to authorities– “We have to report all MDROs to the state.

Who defines MDRO?

You do,Or whomever you’re

producing the data for




precautions.”• Reporting to authorities– “We have to report all MDROs to the state.

Who defines MDRO?

Your infection control team




precautions.”• Reporting to authorities– “We have to report all MDROs to the state.”

Who defines MDRO?

NHSN, CDC, State, Parent Company

Hence, the problem…

Different people doing the defining…

for different reasons…

…leads to different definitions.

I know one when I see one…

MRSA VRE

…well, maybe not.

KPCESBL

Acinetobacter

AmpC

The Simplest Approach

Multi – drug - resistant

Resistant to > 1 drug

classes of drugs>2Non-susceptible to

The Not Quite As Simple But Now The Closest Thing We Have to Universally Accepted Approach

XDR and PDR

Extensively drug resistantNon-susceptible to at least 1 drug in

all but two or fewer classes

Pan drug resistantNon-susceptible to all

agents in all classes

What is a “class” of drugs?

Beta-lactams


Cephalosporins

Penicillins

Monobactams

Carbapenems


1st gen. CephalosporinsAminopenicillins

Monobactams Carbapenems

Ureidopenicillins

Carboxypenicillins

ß-lactamase resistant penicillins

ß-lactamase inhibitor combinations

2nd gen. Cephalosporins

3rd gen. Cephalosporins

4th gen. Cephalosporins

5th gen. Cephalosporins

Cefamycins

What is resistance to a class?

Bug A Bug B Bug C Bug DGentamicin R R R ITobramycin R R S SAmikacin R S S SResistant to this class? Yes Yes Yes Yes

What about intrinsic resistances?

• Should intrinsic resistance count toward number of classes showing resistance?

• Typically chromosomally encoded; those genetic determinants are not easily passed on to other bacteria

• But still can be bad boys – bad infections, bugs can be transmitted to others, hard to treat

If we include intrinsic resistances in our definition, then every single Acinetobacter baumannii, Burkholderia cepacia,

Pseudomonas aeruginosa, and Stenotrophomonas maltophilia we isolate would be considered MDRO.

If we include intrinsic resistances in our definition, then every single Morganella, Proteus, Providencia, and Serratia marcescens we isolate would be considered MDRO.

I’ll refer to this later as the “GBGX”

paper.

22 drugs in 17 classes

MDR – NS to at least one drug in at least 3 classes

XDR – NS to at least one drug in all but 2 or fewer classes

PDR – NS to all drugs in all classes

22 drugs in 17 classes14 drugs in 13 classes




Standardization, but is it practical?Organism What they suggest What’s on our panel

Staphylococcus aureus 22 drugs in 17 classes 14 drugs in 13 classes

Enterococcus 17 drugs in 11 classes 10 drugs in 8 classes

Enterobacteriaceae 32 drugs in 17 classes 23 drugs in 14 classes

Pseudomonas aeruginosa 17 drugs in 8 classes 11 drugs in 6 classes

Acinetobacter 22 drugs in 9 classes 14 drugs in 8 classes




Authors recommend additional designations:

“Possible XDR”

“Possible PDR”

http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf, January 2013

We’ll call this one the “CDC”

paper.

Based on 2008 SHEA/HICPAC Position Paper published in Inf Control & Hosp

Epidemiol, October 2008, vol. 29, no. 10


MDRO Definitions

MRSA Resistant to oxacillin, methicillin, or cefoxitin, or positive by an FDA-approved test for mecA on isolated colonies or in specimens

MSSA Not a MRSA


MDRO Definitions

VRE Any Enterococcus resistant to vancomycin or positive by an FDA-approved test for VRE

Any Klebsiella non-susceptible to ceftriaxone, cefotaxime, ceftazidime, or cefepime***

***Based on new breakpoints

Ceph-RKlebsiella


MDRO Definitions

CRE E. coliNon-susceptible to imipenem, meropenem, or doripenem***, or positive by a test for carbapenemase

***Based on new breakpointsCRE

Klebsiella


MDRO Definitions

MDR Acinetobacter

Back to CRE

http://www.cdc.gov/hai/organisms/cre/cre-toolkit/

Call this one the “CRE Toolkit”

Based on new breakpoints

But maybe not so straightforward…

http://www.cdc.gov/hai/organisms/cre/cre-toolkit/

How many CRE at Norton*?(since January 1, 2010)

True Modified Hodge Positive

Standard definition from CDC’s “CRE Toolkit”

Take away imipenem-NS Proteus, Providencia, Morganella

Include ertapenem NS isolates

*We are still using the “old” cephalosporin and carbapenem breakpoints.

13

28

2237

Mandatory Reporting

• Which definition to use?– Labs using old breakpoints– Labs using new breakpoints

• Infections only, or include colonization?– Mandatory surveillance?– Which method?

• CDC method• Chromogenic media

What We’ve Done• Certain organisms are designated in microbiology laboratory reports

as MDROs.

• The Microbiology Laboratory makes this determination on the basis of full susceptibility results from the MicroScan and supplemental testing if necessary.

• The chief intent is infection control. All patients infected with an isolate reported as an MDRO are put into contact precautions.

• We continue to use pre-2009 CLSI breakpoints for cephalosporins and carbapenems with supplemental testing for beta-lactamases as necessary.

• We generally do not do surveillance cultures to detect colonization, with the exception of weekly MRSA cultures in the NICU.

Our MDRO Definitions

• MRSA – by oxacillin or cefoxitin MIC or by growth on chromogenic medium

• VRE – by vancomycin MIC; E. faecalis and E. faecium only

• E. coli, Klebsiella, and Proteus mirabilis that produces ESBL enzymes

• Certain Enterobacteriaceae that produce plasmid-encoded AmpC enzymes

Our MDRO Definitions

What about other bugs?

Burkholderia cepacia

Stenotrophomonas maltophilia

Streptococcus pneumoniae

Achromobacter xylosoxidans

Is this an MDRO?

Amox/Clav R Linezolid S

Ceftriaxone R Oxacillin R

Clindamycin S Rifampin S

Cefazolin R Trim/Sulfa S

Daptomycin S Tetracycline S

Erythromycin S Vancomycin S

Gentamicin S

Levofloxacin S

Staphylococcus aureus

GBGX: CDC:No Yes

Is this an MDRO?

Amox/Clav S Linezolid S

Ceftriaxone S Oxacillin S

Clindamycin R Rifampin S

Cefazolin S Trim/Sulfa S

Daptomycin S Tetracycline R

Erythromycin R Vancomycin S

Gentamicin S

Levofloxacin R

Staphylococcus aureus

GBGX: CDC:Yes Yes?

Is this an MDRO?

Ampicillin R Linezolid R

Daptomycin S Penicillin R

Nitrofurantoin I Tetracycline R

Gent. Synergy S Vancomycin S

Levofloxacin R

Enterococcus faecalis

GBGX: CDC:Yes No

Is this an MDRO?

Ampicillin S Linezolid S

Daptomycin S Synercid S

Nitrofurantoin S Tetracycline S

Gent. Synergy S Vancomycin R

Levofloxacin S

Enterococcus gallinarum

GBGX: CDC:No Yes

Is this an MDRO?

Amikacin R Gentamicin R

Amp/Sulbactam I Levofloxacin R

Ceftazidime R Meropenem R

Cefotaxime R Tetracycline R

Ciprofloxacin R Trim/Sulfa R

Cefepime R Tigecycline R

Colistin S Tobramycin R

Acinetobacter baumannii

GBGX: CDC:Yes Yes

Is this an MDRO?

Amikacin S Gentamicin S

Amp/Sulbactam S Levofloxacin R

Ceftriaxone I Meropenem R

Ceftazidime S Tetracycline R

Cefotaxime I Trim/Sulfa R

Ciprofloxacin R Tobramycin S

Cefepime S

Acinetobacter baumannii

GBGX: CDC:Yes No

1

2

345

1

2

Is this an MDRO?

Amikacin R Imipenem S

Aztreonam R Levofloxacin S

Ceftriaxone R Meropenem S

Ceftazidime R Pip/Tazo R

Cefotaxime R Piperacillin R

Ciprofloxacin S Trim/Sulfa R

Cefepime R Tetracycline S

Gentamicin R Tobramycin R

Achromobacter xylosoxidans

GBGX: CDC: Species notaddressed

Species notaddressed

Is this an MDRO?

Amikacin S Imipenem S

Aztreonam R Levofloxacin R

Ceftazidime S Meropenem S

Ciprofloxacin R Pip/Tazo S

Cefepime S Piperacillin S

Gentamicin I Tobramcyin S

Pseudomonas aeruginosa

GBGX: CDC:Yes Species notaddressed

1

2

3

Is this an MDRO?

Amp/Sulbactam S Ertapenem S


Ampicillin R* Levofloxacin S

Ceftriaxone R* Meropenem S

Ceftazidime R* Pip/Tazo S

Cefazolin R* Trim/Sulfa S

Ciprofloxacin S Tetracycline S

Cefepime R* Tobramycin S

Escherichia coli

GBGX: CDC:Presumably No

Old breakpoints

ESBL positive

Is this an MDRO?

Amp/Sulbactam R Ertapenem S


Ampicillin R Levofloxacin S

Ceftriaxone S Meropenem S

Ceftazidime S Pip/Tazo S

Cefazolin R Trim/Sulfa S

Ciprofloxacin S Tetracycline S

Cefepime S Tobramycin S

Citrobacter freundii

GBGX: CDC:No

1

2

3

Species notaddressed

Is this a CRE?

Amp/Sulbactam R Cefazolin R

Ampicillin R Cefepime S

Amox/Clav R Cefuroxime R

Aztreonam R Ertapenem R

Ceftriaxone R Imipenem I

Ceftazidime R Meropenem S


Cefoxitin R Pip/Tazo I

Klebsiella pneumoniae

CDC: CRE Toolkit:Yes Yes

Is this a CRE?




Aztreonam R Ertapenem R

Ceftriaxone R Imipenem I




Providencia rettgeri

CDC: CRE Toolkit: NoSpecies notaddressed

New breakpoints

Is this a CRE?




Aztreonam S Ertapenem S

Ceftriaxone S Imipenem I

Ceftazidime S Meropenem S

Cefotaxime S Piperacillin R

Cefoxitin R Pip/Tazo S

Serratia marcescens

CDC: CRE Toolkit: NoSpecies notaddressed

New breakpoints

Is this a CRE?




Aztreonam R Ertapenem I

Ceftriaxone R Imipenem S




Enterobacter cloacae

CDC: CRE Toolkit: PerhapsSpecies notaddressed

So what to do?

• Will the lab designate isolates as MDRO?• Why? What’s your purpose? How will the data be

shared?• Create meaningful definitions that fit your purpose.• Continue to follow good selective reporting, but

include non-reported drugs in determining MDRO status.

• Make determination of MDRO status as easy as possible. Automate if possible.

And thanks to Siemens for their sponsorship of this program.

Thank your for your attention.

[email protected]

The Alan D. Junkins, PhD, D(ABMM) of Multi- Drug- Resistant Organisms Sponsored by an educational...

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