MANAGEMENT OF MULTIRESISTANT

NOSOCOMIAL INFECTION

Infectious Diseases Unit

Internal Medicine Department

Hasan Sadikin General Hospital / Faculty of Medicine

Padjadjaran University

DEFINISI

• Infeksi nosokomial• Bakteri multiresisten

PROBLEM

• Lokal

Nasional

global

• Klinisi

Farmasi

Pengelola

POINTS

• Faktor Resiko• Pencegahan• Terapi

Kolonisasi

Infeksi

Terjadinya

Penyebaran

● CCU

INANIMATE ENVIRONMENT

PATIENTSHCW

● Critically ILL patients

Ecosystem of microorganism

Endogenous flora

Less pathogen Resistant pathogen fungi

Selective pressureOf Antibiotic

- Chromosom- plasmid

Faktor Resiko

• Inappropriate antibiotic therapy

• Prolong antibiotic therapy

• Wrong combination antibiotic therapy

• Infeksi sulit / multipel

• Terapi kolonisasi

• Standar / peraturan / policy ( - )

Manardi 1998Cunha 1998,2002

Pencegahan timbulnya kuman multi resisten• Batasi antibiotik yang potensial terjadi

resistensi

• Usahakan antibiotik yang kurang potensial terjadinya resistensi

• Rotaring formulary (cycling) ?

• Monoterapi > kombinasi

• Pengenalan antibiotik failure

• Indikasi tepat untuk antibiotik tertentu

Spreading of Resistant pathogen

• Invasive diagnostic

• Invasive therapeutic

• Devices,clothe, linen

• HCW

Frequency

intencityRisk of noso. inf

Pencegahan penyebaran kuman multi resisten• Surveilance

• Universal precaution, droplet precaution, contac precaution, air borne precaution

• Empiric precaution

• Isolation (BSI, single room, cohort)

• Peraturan antara lain transportasi

Hand washing

DIAGNOSTIK MDR

• Reliable laboratorium

• Regular report

• Early detection

Antibiotic policies / noso. control program

• Guidelines

• Education, out break investigation, surveilance• Committee/ :- clinician

team - microbiologist - pharmacist - administration, epidemiologist - nurse

• Antibiotic – resistance pattern report & routine feedback.• Restriction : (indication)

- high potential to resistance- broad spectrum

National & local

Control the emergence of resistant strains

KAKKILAYA (2005)

We must exercise considerable restraint in prescribing antibacterials. Restrict a.b use to only certain definite indications

Definitivetherapy

Empiricaltherapy

Prophylactictherapy

Cost-effective : Narrower spectrum; SE

Cheaper; easy adm; resistency

• 50 % A. B. use in CCU : unjustification/ documented (-)• Review → report : Antibiotic pattern• Reliable culture results ↔ clinical entity• Modification / reassesment

– Change– Superinfection– Non infection– Drug fever

Combination

• Monoterapi is preffered

• Certain indication

- anti TBC

- anti pseudomonas

- mix infection → spectrum ↑

• Combination resistant m.o?

Rotation (cycling)

• Controversi

• Resistance to both agents

still emerge

• Alternative to restriction

Vancomycin use (avoid VRE)

acceptable Discouraged

1. Betalactame resistance m.o

2. Gram + infection but betalactam allergy

3. Antibiotic – associated colitis + fails to metronidazol

1. MSSA

2. Skin contamination with Staphyloccocus is likely

3. Continued empiric use, while culture ( - ) for betalactam resistant gram positive

4. MRSA colony eradication

5. Topical use

Hand washing / Antiseptic

• Simple, education!• Studies : - Sampling of physician hand : gram (-) rod, S. aureus

- Routine washing → skin bact. Carriege → noso. Infection

• “before and after contact” (patient/procedure/source/gloves)• Antiseptic soap/solution : e.g chlorhexidine

water/plain soap → Heavy contamination?• Gloves → Physical barrier

Surveillance

• Most important of inf. Control program• Baseline Rate; infection rate

recognition of potential outbreaks

early identification : - special patients

- resistant m.o

- outbreaks• Collecting, analyzing

• Re-usable device : - disinfection - sterilization

• Physical plant/Engineering- facilitate inf. controle- limit infection spread

• Isolation precaution (private,cohort)• Droplet precaution (e.g meningococus, MRSA)• Airborne precaution ( e.g TBC)• Contact precaution ( e.g MRSA, VRE)

MDR Noso. Infection

• Easy to be transmitted :

VRE

MRSA

• Others :

- ESBL-gram negative (e.g pseudomonas)

- MDR TB

- GISA

Pengobatan MDR Pathogin

• Sulit

• Jenis kuman? Pola resistensi?

• MRSA

VREMudah menyebar

MRSA (Methicillin-resistant Staph. Aureus)

• Resistant to : betalactam, and usually (occassionally) other antibiotics

• Special lab test

• Readily & easily transmitted

• Difficult & expensive to control and to treat

(1)

MRSA

• Good colonizers • Transmission : hand of HCW, equipment, clothing,

air.• Screening : admission, staff• Notify it transferred• Isolation for patients and treat (single or cohort

room?)• Treatment infected patients :

- Vancomycin- Vancomycin + gentamycin /

rimfampycin / cotrimmoxazole

(2)

MRSA

• Sampling sites : 2/3 negative results

(patients, room)

clearance

• MRSA control

- Surveillance → early detection

- Isolation & treatMupirocin topical 2% chlorhexidine 1% neomycinbacitracin

Nasal (local) 1 week

(3)

MRSA

• Bathing (shower) 1 week

• Prophylactic : during outbreaks• Droplet precaution• Hand washing + disinfection• Gloves, apron, gown when handling

patients• Disinfecting before opening

Chlorhexidine 2% triclosan

(4)

VRE = glycopeptide resistant Enteroccocus

• Resistance to vanco and other agents (aminoglycoside, ampicillin)

Difficult to treat• Risk factors : - broad spectrum A.

- vancomycin - prolonged hospitalization - others

• Measures to limit the spreadeg.: - strict limitation of vancomycin

- precautions• Treatment : - linezolid; quinepristin/dalfopristin

- UTI : Nitrofurantoin, Fluoroquinolon

Strep. Pneumoniae

• Resistance to : Penicillin cephalosporin

a.l macrolide, tetra, chloramph.• Pattern ~ lokalisasi• Th/: - mic < 2 mg/L to penicillin dosis / cefotaxime,

ceftriaxone

- high level of resistance: imipenem,glycopeptides

- pnemococcal menginitis : ceftriaxone + vanco.

Pseudomonas Aeruginosa

• The most adaptable m.o

• Resistance to ceftazidine

to : amikacin

cipofloxacin

imipenem

PROBLEM

• Kasus : multiresistant klebsiella

♂, 70 th, strokeurine culture : K. pneumoni yang resistensi semua A.B kecuali imipenem

• Marin Kollef (2003) : Gr-(e.g Kleb.Pn; E. Coli often produce ESBLs

• Reese (1996) multidrug resistant outbreak of klebsiella spp have been reported.They are still susceptible to imipenem.

• LEVLY :

To deal with MDR m.o

all of us: physician, patient, microbiologist

pharmacist, P.H/epidemiologist, infection control practitioner.

• Some MDR pathogen untreatable

• Closely monitor individual (local) antibiogram

• Preventing MDR - m.o most logical approach

• Surveillance : a.b – m.o - infection

KESIMPULAN

1. Waspadai terjadinya dan penyebaran kuman multiresisten di rumah sakit

2. Kenali faktor resiko

3. Pencegahan terjadinya kuman tsb.

4. Deteksi dini - cegah penyebaran

- pengobatan