By Dr. Sherif Ibrahim 1. Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology Review epidemiology of MDROs ◦ Reservoir

By Dr. Sherif Ibrahim

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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology

Review epidemiology of MDROs◦ Reservoir◦ Mode of transmission ◦ Type of infection ◦ Role of environment

Review specific MDROs Prevention strategies Contact Precautions Exercise

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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

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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

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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

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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

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Enterococcus faecium (VRE)

Staphylococcus aureus (MRSA)

Clostridium difficile (C. Diff)

Acinetobacter baumannii

Pseudomonas aeruginosa

Enterobacteriaceae (CRKP/CRE)

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Methicillin‐Resistant Staphylococcus aureus (MRSA)

Vancomycin‐Resistant Enterococci (VRE)

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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………

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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

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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)

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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)

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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

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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

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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 Klebsiella accounted for 15% all HAIs reported to NHSN 2007

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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

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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 ……

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2001

Geographical Distribution of KPC-Producers

Sporadic isolate(s)

Centers for Disease Control and Prevention.

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Widespread

Sporadic isolate(s)

2006



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2010


Sporadic and Widespread isolate(s)


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Antimicrobial Interpretation Antimicrobial Interpretation

Amikacin I Chloramphenicol R

Amox/clav R Ciprofloxacin R

Ampicillin R Ertapenem R

Aztreonam R Gentamicin R

Cefazolin R Imipenem R

Cefpodoxime R Meropenem R

Cefotaxime R Pipercillin/Tazo R

Cetotetan R Tobramycin R

Cefoxitin R Trimeth/Sulfa R

Ceftazidime R Polymyxin B MIC >4mg/ml

Ceftriaxone R Colistin MIC >4mg/ml

Cefepime R Tigecycline S

0

10

20

30

40

50

60

Overall Mortality AttributableMortality

Pe

rce

nt

of

sub

ject

s CRKPCSKP

p<0.001

p<0.001

2048 1238

OR 3.71 (1.97-7.01)OR 4.5 (2.16-9.35)


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

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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 …..

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Most common gram negative carried by skin of HCPMost common gram negative carried by skin of HCP

Frequently colonizes tracheostomy site

Chlorohexidine resistance

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

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Widespread environmental contamination


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%

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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

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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

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Core Measures Administrative supportSurveillancePatient placement Patient/staff cohortingHand hygieneContact precautionsProtocol for lab notificationDedicated equipment Device useEnvironmental measuresMonitor compliance Education Antimicrobial stewardship

Supplemental Measures Preemptive isolation Active surveillance culture Chlorohexidine bathing

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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

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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.

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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

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Number of annual cases

Cost Number of annual deaths

Hospital-onset, hospital acquired (HO-HA)

165,000 $ 1.3 B 9000

Nursing home-onset 263.000 $ 2.2 B 16,500

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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

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Antimicrobial stewardship

Admitted to healthcare facility

Antimicrobials

C Diff exposure & acquisition

Colonized no symptoms

Infected Symptomatic

Optimizing Environmental cleaning and Hand Hygiene


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

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Core MeasuresSurveillanceContact Precautions (CP) for duration of diarrheaHand hygiene (HH) Dedicated equipment Cleaning and disinfection of equipment and environmentLaboratory-based alert system for immediate notification Educate HCP, housekeeping, admin staff, patients, families, visitors, about CDI Monitor compliance


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.)

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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

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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)

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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

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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.

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Questions

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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

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