MDROs 101 Multidrug-Resistant Organisms

1. MDROs 101 Multidrug-Resistant Organisms By Dr. Sherif Ibrahim

2. Objectives • Review epidemiology of MDROs • Reservoir • Mode of transmission • Type of infection • Role of environment • Review specific MDROs • Prevention strategies • Contact Precautions • Exercise

3. Multi-Drug Resistant Organisms (MDROs) Epidemiology • Definition: • microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents • Importance: • Limited options for treatment • Increase the length of stay and cost of hospitalization • Increase admission to and stay in ICU • High mortality rates

4. MDROs - Epidemiology • Transmission: • Mainly person to person through hands of healthcare personnel (HCP) • Contact with contaminated environmental surfaces • Transmission depends on • Availability of vulnerable patients • Antimicrobial pressure • Colonization pressure • Adherence to infection control measures • Frequent movement among healthcare facilities

5. MDROs – Epidemiology • Reservoirs • Infected 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

6. MDROs – Epidemiology • Infected: a person who has culture-positive for an MDRO and displays signs or symptoms of infection • Colonized: a person who has culture-positive for an MDRO but has no signs or symptoms of infection

7. Important MDROs ESCAPE Enterococcus faecium (VRE) Staphylococcus aureus (MRSA) Clostridium difficile (C. Diff) Acinetobacter baumannii Pseudomonas aeruginosa Enterobacteriaceae (CRKP/CRE)

8. Gram Positive MDROs • Methicillin‐Resistant Staphylococcus aureus(MRSA) • Vancomycin‐Resistant Enterococci (VRE)

9. MRSA – Epidemiology • Staph aureus(SA)resistant to beta‐lactams. • 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 • Reservoirs: ……. and……... • Transmission…… and………

10. MRSA – Epidemiology • 49-65 % of HA-Staph infections NHSN • 94,360 invasive MRSA infections annually/US • 18,650 associated deaths • 86% of all invasive MRSA are HAIs • Staphylococcus aureus • Intrinsic virulence • Cause a wide range of life threatening infections • Adapt to different environmental conditions • Can survive in the environment 1-56 days

11. Prevention and Control • MRSA colonization generally precedes infection • Risk of developing MRSA infection among colonized individuals is 29% in 18 months • Rationale for prevention • Prevent transmission from colonized to un-colonized individuals • Prevent infection in colonized individuals • MRSA-specific strategies (Decolonization) • Non MRSA-specific strategies (reduce device-associated infections)

12. Vancomycin‐Resistant Enterococci (VRE) Epidemiology • Aerobic Gram positive cocci that inhabitant of GI tract and female genital tract • Endemic in most U.S. hospitals • 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)

13. VRE Epidemiology • Reservoirs: ….. and …….. • Transmission: ……and …… • 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

14. Gram Negative MDROs • Glucose fermenter (Enterobacteriaceae) • Foodborne (Salmonella, Shigella) • Healthcare-associatedEnterobacter species (E. cloacae) • Community and Healthcare-associated • Klebsiella species (K. pneumoniae) • Escherichia coli • Non–glucose fermenters • Acinetobacter baumannii • Pseudomonas aeruginosa

15. Enterobacteriaceae Epidemiology • Normal human gut flora • Environment (soil & water) • Important cause of community and HA infections • Wide range of infections (UTI, Bacteremia, pneumonia, wound infection) • E. coli most common cause of outpatient UTIs • E coli and Klebsiellaaccounted for 15% all HAIs reported to NHSN 2007

16. Development of Antimicrobial-Resistant Enterobacteriaceae • B lactamases  resistant to B-lactams for decades • Extended 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

17. 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) • Reservoirs: ……..and ….. • Transmission; …..and ……

18. Geographical Distribution of KPC-Producers Sporadic isolate(s) 2001 Centers for Disease Control and Prevention.

19. Geographical Distribution of KPC-Producers Widespread Sporadic isolate(s) 2006 Centers for Disease Control and Prevention.

20. Geographical Distribution of KPC-Producers Sporadic and Widespread isolate(s) 2010 Centers for Disease Control and Prevention.

21. Susceptibility Profile of KPC-Producing KP

22. Mortality Associated with CRKP p<0.001 p<0.001 38 48 20 12 OR 3.71 (1.97-7.01) OR 4.5 (2.16-9.35)

23. CRKP in Long-Term Care Facilities • Few clinical cases  large reservoir of colonized patients in LTCFs. • Colonization rate was as high as 49% in one outbreak • Recipe for CRKP outbreaks: • Infection control breaches (lack of compliance) • Unrecognized colonized residents serving as reservoirs for transmission

24. MDR- Acinetobacter baumannii (Ab)Epidemiology • Non-motile gram negative bacteria (32 species) • Ubiquitous  widely distributed in nature (soil, water, food, sewage) & the hospital environment • MDR-Ab is primarily a nosocomial pathogen • Long survival time on inanimate surfaces extensive environmental contamination • Transmission …. and…… • Reservoirs: …… and …..

25. MDR- Ab Epidemiology • Respiratory care equipment • Bed rails, Bedside tables, • Mattresses, Pillows • Curtains, door handles • Keyboards • Floor mops, sinks • Air humidifiers • Patient care items • Wound care procedures • Equipment carts, • Infusion pumps • Patient monitors and X-ray board Widespread environmental contamination Most common gram negative carried by skin of HCP Most common gram negative carried by skin of HCP Frequently colonizes tracheostomy site Chlorohexidineresistance

26. MDR- Ab Epidemiology • MDR- Acinetobacter mainly causes HAIs • Pneumonia (Ventilator-associated pneumonia) • Urinary tract • Bacteremia • Meningitis • Skin/wound infections • MDR- Acinetobacter infections • Acute care (ICUs) traditionally, associated with outbreaks • LTAC & LTCFs • Injured military personnel • Outbreaks  mortality rates up to 75%

27. MDR- Pseudomonas aeruginosa Epidemiology • 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 individuals • At Risk individuals: • Immuno-compromised • Burn patients • Patients on mechanical ventilation • Cystic fibrosis patients

28. P. aeruginosaEpidemiology • 10% of all hospital-acquired infections • Often cause severe life threatening HAIs • Can be found everywhere • Can be community acquired • In healthcare facilities: respiratory equipment, food, sinks, taps, toilets, weak disinfectants, showers and mops, uncooked vegetables, flower water • Transmission …..and ………. • Reservoirs ……. and ………… • Colonization precedes infection in 50% of cases

29. Prevention Strategies (MDROs) Core Measures • Administrative support • Surveillance • Patient placement • Patient/staff cohorting • Hand hygiene • Contact precautions • Protocol for lab notification • Dedicated equipment • Device use • Environmental measures • Monitor compliance • Education • Antimicrobial stewardship Supplemental Measures • Preemptive isolation • Active surveillance culture • Chlorohexidine bathing

30. C. difficile : Epidemiology • Gram positive spore forming bacillus (rods) • Obligate anaerobe • Part of the GI Flora in • 1-3% of healthy adult • 70% of children < 12 months • Some strains produce toxins A & B • Toxins-producing strains cause C. diff Infection (CDI) • CDI ranges from mild, moderate, to severe and even fatal illness

31. C. difficileEpidemiology Transmission • Fecal – oral route • Contaminated hands of healthcare workers • Contaminated environmental surfaces. • Person to person in hospitals and LTCFs • Reservoir: • Human:colonized or infected persons • Contaminated environment • C. diff spores can survive for up 5 months on environmental surfaces.

32. C. difficile: Epidemiology • A common cause of nosocomial antibiotic-associated diarrhea (AAD) • Most common infectious cause of acute diarrheal illness in LTCFs • The only nosocomial organism that is anaerobic and forms spores • Infective dose is < 10 spores

33. CDI: Impact

34. Clinical Manifestations • Illness caused by toxin-producing strains of C. difficile ranges from • Asymptomatic carriers = Colonized • Mild or moderate diarrhea • Pseudo membranous colitis that can be fatal • A median time between exposure to onset of CDI symptoms is of 2–3 days • Risk of developing CDI after exposure ranges between 5-10 days to 10 weeks

35. Rationale for Preventive strategies Colonized no symptoms Antimicrobial stewardship Antimicrobials C Diff exposure & acquisition Optimizing Environmental cleaning and Hand Hygiene Admitted to healthcare facility Infected Symptomatic

36. Preventive Strategies: C. Diff • Core Measures • Surveillance • Contact Precautions (CP) for duration of diarrhea • Hand hygiene (HH) • Dedicated equipment • Cleaning and disinfection of equipment and environment • Laboratory-based alert system for immediate notification • Educate HCP, housekeeping, admin staff, patients, families, visitors, about CDI • Monitor compliance Supplemental Measures • Extend (CP) beyond duration of diarrhea (48 hours) • Presumptive isolation for symptomatic patients • Implement soap and water for HH before exiting room of a patient with CDI • Implement universal glove use on units with high CDI rates • Use sodium hypochlorite (bleach) - containing agents for environmental cleaning • Implement an antimicrobial stewardship program

37. Contact Precautions (CP) • Patient placement (factors to consider) • Hand hygiene (HH) • Gloves • Don gloves upon room entry • Change gloves after contact with infectious materials • Change gloves when moving from contaminated to non contaminated site • Remove gloves and HH before leaving the room or caring for another patient • Gowns • Don gown upon room entry • Remove and discard gloves before removing gown • Discarding gown before exiting the room • After gown and gloves removal HH make sure not to touch any potentially contaminated environmental surface in the room • Dedicated equipment (BP cuff, stethoscope, thermometer, etc.)

38. Contact Precautions in LTCFs • Challenges of implementing CP in LTCFs • Contact Precautions should be used for the following residents with MDROs • Dependent on HCP in their activities of daily life • Ventilator-dependent • Incontinent of stool • Wound with difficult to contain discharge • Contact Precautions can be relaxed for all others residents with MDROs (consider resident’s mental status and personal hygiene) • Standard precautions should be observed all times • Dedicated equipment • Signage for HCP and visitors

39. Conclusion • MDROs represent a major clinical and infection control challenge particularly in LTCFs • You cannot do it alone  Regional approach • Aggressive infection control approach works • Appropriate antimicrobial use • Training and education (HCP, Patients, Families) • Communications (intrafacility and interfacilities)

40. Exercise • During morning rounds you were assigned rooms 103 and 107 for the day • Room 103 • Under contact precautions • Has 2 patients • Patient #1 was recently treated for CRKP UTI, has a Foley catheter and is stool incontinent • Patient # 2 is CRKP colonized and has a deep bedsore in the right buttock • Room # 107 • Has two residents admitted for short term rehabilitation S/P total knee replacement. One of them is stool incontinent

41. Questions • What type of precautions would you use upon entering Room 103 and why? • How is this type of organism transmitted? • What type of precautions will you be using for room 107 and why? • Do you think it is a good practice to provide care for these two rooms in the same day? Please explain why and what is the best practice in this situation? • Patient # 2 in room 103 is ambulatory and he wants to go to the activity room. What would you do? • In the schedule, all four patients are due for bathing. Specify who would go first.

42. Questions

43. Resources and References • SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility http://www.dhhr.wv.gov/oeps/disease/AtoZ/Documents/SHEA%20Guide%20to%20LTCF%20Infection%20Control%20Jul08.pdf • Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf • Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006 http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdf • DIDE Website http://www.dhhr.wv.gov/oeps/disease/HAI/Pages/default.aspx • CDC Healthcare-Associated Infections http://www.cdc.gov/hai/ • CDC SHEA “Train the Trainer” May 2011 • Epidemiology and Prevention of Common Emerging MDROs “Alex Kallen, MD, MPH” DHQP, CDC