Management of Multidrug-Resistant Organisms (MDROs) in Long-term Care Facilities

1. Management of Multidrug-Resistant Organisms (MDROs) in Long-term Care Facilities Kirk Huslage, RN, BSN, MSPH, CIC Associate Director

2. Learning objectives • Name three emerging multidrug-resistant organisms (MDROs) being detected in LTCFs • Describe two challenges to implementing contact precautions in LTCFs • List two important issues relating to infection prevention in LTCFs

3. Changing population in nursing homes 3.3 million residents received care in 16,000 NH/SNF CMS Nursing Home Compendium, 2010

4. From 1999 to 2008 CMS Nursing Home Compendium, 2010

5. Shifting proportions • Increase in the number of residents <65y/o • 12.9% (2005) to 14.2% (2009) • Increase in functional impairment (extensive assistance with at least 4 of 5 ADLs) • 42% (2005) to 52% (2009) • Growing population of short-stay, post-acute residents as custodial care shifts to assisted living. CMS Nursing Home Compendium, 2010

6. Growing complexity in the NH resident population • Increased post-acute care population • Growing medical complexity • Increased exposure to devices, wounds, and antibiotics • Dynamic movement across healthcare settings • High prevalence of multidrug-resistant organisms

7. Bacteria basics • Bacteria have different characteristics that allow us to identify them in the lab • Growth patterns, structure of the cell • We use these characteristics to help make treatment decisions

8. Common types of bacteria Gram Positive Gram Negative Most are rod shaped (baccilli) bacteria Enterobacteriaceae: E. coli, Klebsiella, Enterobacter, Proteus Pseudomonas • Most are round (cocci) bacteria • Streptococcus, Staphylococcus, Enterococcus • Clostridium difficile (C. diff) is Gram positive rod

9. Normal bacterial carriage • We have bacteria living in and on us all the time • Our bodies need these bacteria • Digest nutrients, block bad bugs • These “colonizing” bacteria aren’t harmful • Only bacteria that invade our system and cause disease need to be treated

10. Antibiotic basics • Antibiotics treat and kill bacteria • Grouped into classes based on structure and activity • Narrow-spectrum target few bacteria • Broad-spectrum kill a wide range of bacteria • Microbiology labs and infection prevention programs track certain “bug-drug” combinations for evidence of increasing resistance

11. Antibiotic classes Penicillins Cephalosporins Cousins to penicillins 1st generation (more gram positive activity Cephalexin, Cefazolin 3rd/4th generation (more gram negative activity) Ceftriaxone, Ceftazidime • Penicillin, amoxicillin, ampicillin, methicillin • Often combined with other drugs to overcome resistance • Amoxiciilin + Clavulante = Augmentin • Piperacillin + Tazobactam = Zosyn

12. Antibiotic classes Carbapenems Miscellaneous Mostly Gram positive activity Vancomycin, linezolid, daptomycin Vancomycin used to treat MRSA Oral vancomycin ONLY used to treat C. difficile IV used for all other infections • Imipenem, meropenem, doripenem, ertapenem • Extremely broad spectrum, very powerful

13. Antibiotic classes Fluoroquinolones Aminoglycosides Gentamycin,Tobramycin, Amikacin Excellent Gram negative drugs – UTIs Limited use because of kidney toxicity, monitor when using • 1st generation (Ciprofloxacin) mostly gram negative, used to treat UTIs • 2nd/3rd generation (Levofloxacin/Moxifloxacin) broader activity, used for respiratory/sinus bacteria

14. Antibiotic classes More Miscellaneous drugs • Trimethoprim/Sulfamethoxazole (Bactrim): Has Gram positive and negative activity – UTIs, MRSA skin infections • Azithromycin (Z-pack): Narrow spectrum – respiratory/sinus infections • Metronidazole (Flagyl): Main treatment for C. difficile infections

15. Mechanisms of resistance Production of proteins that destroy antibiotics – β – lactamases, carbapenemases Change cell structure so antibiotics can’t bind and block function • Reduce antibiotic exposure • Pump drugs out • Increase cell barriers to keep drug out

16. Defining multidrug-resistance • Resistance to treatment by several antibiotics from different classes • Sometimes just one drug defines resistance – Methicillin-resistance in Staphylococcus aureus • Sometime bacteria acquire resistance to several classes – Gram negative rods • Cephalosporin-resistance in E. coli and Klebsiella • Pseudomonas resistant to fluoroquinolones, penicillins, cephalosporins, and carbapenems

17. A Better Term: Epidemiologically Important Pathogens Any infectious agent that have one or more of the following characteristics • Propensity for transmission within facilities • Antimicrobial resistance implications • Associated with serious disease; increased morbidity and mortality • A newly discovered or re-emerging pathogen

18. More on Epidemiologically Important Pathogens • Some really bad pathogens are not multi-drug resistant • MSSA • Group A strep • C. difficile • Similar strategies used to control MDROs used to control pathogens other than MDROs

19. ABC’s of MDROs

20. MDRO development healthcare settings • Antibiotic pressure • Prior antibiotic exposure is predictive for antibiotic resistance • Device utilization • Biofilm formations on indwelling devices

21. Antibiotic Pressure

22. Antibiotic resistance cycle

23. Biofilms on device surfaces Resistance Attachment Expansion Maturation

24. How resistance develops in biofilms • Bacteria with biofilms grow differently than free floating bacteria • Antibiotics cannot penetrate the biofilm • Bacteria within a biofilm talk to each other and share traits that allow some to become resistant Tenke P. World J Urol. 2006; 24:13-20

25. MDROs spread in healthcare settings • Resident to resident transmission via healthcare provider’s hands • Environmental/equipment contamination • Colonization pressure

26. Bacterial contamination of hands prior to hand hygiene in a LTCF • Gram negative were the most common bacteria cultured from hands • Most Gram negative bacteria live in the bowels or colonize the urine!! Mody L, et al. Infect Control HospEpi. 2003; 24:165-71

27. Hand Hygiene • Most effective and least costly means of preventing the transmission of MDROs • Still have poor compliance of around 40% (range 30-60%)

28. Stiefel U, et al. ICHE 2011;32:185-187 Environment-to-Hand-to-Patient 40% 45% Pathogens can be transferred from hospital surfaces to HCP hands without direct patient contact

29. Reservoir of MDROs X marks the location where VRE was isolated in the room Image from Abstract: The risk of hand and glove contamination after contact with a VRE + patient environment. Hayden M, ICAAC, 2001, Chicago, Il.

30. Survival of Pathogens on Surfaces Kramer A, et al (2006). BMC Infect Dis; 6:130

31. Increased Risk from Prior Occupant Otter J, et al. Infect Control Hosp Epidemiol. 2011; 32:687-699

32. Thoroughness of Cleaning Mean = 32% Carling P, et al. APIC, 2012

33. Colonization pressure • The presence of other MDRO (MRSA, VRE, C. difficile) carriers on a unit will increase the risk of MDRO acquisition to a non-carrier close by • Both asymptomatic carriers (colonized) and actively infected individuals can be a source for transmission (spread) on a unit

34. Unit A Unit B Fewer residents with active C. difficile infection = lower risk of acquiring C. difficile More residents with active C. difficile infection = higher risk of acquiring C. difficile

35. Key MDRO prevention strategies • Assessing hand hygiene practices • Quickly reporting MDRO lab results • Implementing Contact Precautions • Recognizing previously colonized residents • Strategically place residents based on MDRO risk factors • Careful device utilization • Antibiotic stewardship • Inter-facility communication

36. Assessing hand hygiene Hand hygiene is one of the most effective measures to reduce HAIs and avoid preventable deaths • Hand hygiene intervention should include: • Easy access to soap and water/alcohol-based hand rubs • Observation of practice – particularly before and after contact with residents or their immediate environment • Provide feedback – “on the spot” feedback is preferred when failure is observed

37. Reporting and recognition of MDRO lab results • Facilities should have a protocol for rapidly reporting positive MDRO lab results to clinicians • Facilitates quick initiation of interventions • Consider empiric precautions while awaiting lab results • Contact precautions for resident with diarrhea

38. Contact precautions - yes, no, or maybe 54 y/o male transferred to your facility for short-term rehab following a total hip replacement • Had a positive MRSA nasal swab pre-operatively • no signs of active infection on admission • Transferred with urinary catheter in place Do you place him on Contact Precautions?

39. CDC says… HICPAC, Management of MDROs in healthcare settings, 2006

40. Key elements of Standard Precautions • Hand hygiene • Personal protective equipment (PPE) • Respiratory hygiene/cough etiquette • Safe injection practices • Environmental controls • Safe laundry practices • Resident placement • Waste management

41. The golden rules for hand hygiene Hand hygiene must be performed exactly where you are delivering health care to patients (at the point-of-care) During health care delivery, there are 5 indications when it is essential that you perform hand hygiene To clean your hands, you should prefer handrubbingwith an alcohol-based formulation, if available. Why? Because it makes hand hygiene possible right at the point-of-care, it is faster, more effective, and better tolerated. You should wash your hands with soap and water when visibly soiled, after care of resident with diarrhea, before and after eating or handling food, and after using the bathroom You must perform hand hygiene using the appropriate technique and time duration

42. Indications for hand hygiene Clean your hands immediately before accessing a critical site with infectious risk for the patient! To protect the patient against harmful germs, including the patient’s own, entering his/her body! Clean your hands when leaving the patient’s side, after touching a patient and his/her immediate surroundings, To protect yourself and the health-care environment from harmful germs! Clean your hands as soon as a task involving exposure risk to body fluids has ended (and after glove removal)! To protect yourself and the health-care environment from harmful germs! Clean your hands before touching a patient when approaching him/her! To protect the patient against harmful germs carried on your hands! Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving without having touched the patient! To protect yourself and the health-care environment against germ spread!

43. When to use PPE Gloves: • Before any possible contact with blood/body fluids, mucous membranes (eyes, nose, mouth) or potentially infectious materials (contaminated medical equipment or waste)

44. When to use PPE Gowns: • To protect skin and clothing during situations where blood or body fluids may spray or splatter or care of resident could result in contamination of skin/clothing

45. When to use PPE Face mask or shields • To protect eyes during situations where blood or body fluids may spray or splatter

46. Hand Hygiene • Before/after PPE use • During resident care Gown and Glove for direct resident care • Don prior to room entry • Remove prior to exit Dedicated non-essential items for resident care • Decrease transmission • BP cuffs, Stethoscopes, etc Private room or cohort resident if possible

47. Difficulties with Contact Precautions • Lack of private rooms and limited ability to move residents • Determining the duration of Contact Precautions • Unable to restrict resident mobility and socialization/therapy for long periods • Unlikely to document clearance of carriage • Large population of residents with unrecognized MDRO carriage

48. Recognizing prior colonization • Residents can be colonized with MDROs for months • Identifying previously colonized or infected residents allows for timely interventions • Knowledge allows for planning the safest care • For every known MDRO carrier, there are probably 3 others we don’t know

49. Placement of residents based on risk factors • Avoid placing 2 high-risk residents together • Safer to cohort low-risk and high-risk residents • Don’t change stable room assignments based on culture results unless it poses new risk • Long-term Roommates have already shared organisms in the past (even if you just learned about it)

50. Resident characteristics to consider – “the 5 C’s” • Cognitive function (understands directions) • Cooperative (willing and able to follow directions) • Continent (of urine or stool) • Contained (secretions, excretions, or wounds) • Cleanliness (capacity for personal hygiene) Kellar M. APIC Infection Connection. Fall 2010 ed.