Emerging Infection ( Dr. Latre Buntaran,Spmk )

7/23/2019 Emerging Infection ( Dr. Latre Buntaran,Spmk )

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Emerging Infections,Emerging Infections,Prevention & ControlPrevention & Control

Latre BuntaranLatre BuntaranDepartment of MicrobiologyDepartment of Microbiology

RSAB “ Harapan Kita “RSAB “ Harapan Kita “



Introduction of MRSA

1961 : Barber, Europe

Mid 19! : Bo"ce #$M , %'

19( : cragg #$) , out* 'frica

19(+ : Mc onald P$# , 'ustralia



Methicillin Resistant Staphylococcus aureus

ransfer

!ommunity

"osocomial

#$Moreno et al % !linical Infectious Diseases &''( ) *& + &,-. / &,&*



Incidence of MRSA +

&0- patients1 2-%* per &$--- patients / days3

Community 99 ( 58% )

Nosocomial 48 ( 28.5% )

Transfers 23 ( 3.5% )

! "urin# a 2$month perio

&.'oreno et alClinical nfectious "iseases 995 * 2 + 3,8 $ 32



Mechanism of Methicillin

Resistance

&$ Intrinsic Methicillin Resistance 2 MRSA 3

Due to production of 4B4 *5 2 lo6 affinity for7arious 8/lactams 3

!hromosomally mediated and encoded by themec gene

Multiple resistance to antimicrobials of se7eralclasses

*$ Ac9uired or Borderline Resistance 2 B:RSA 3

Due to hyperproduction of penicillinase MI! o;acillin + & < * =g>ml "ot multi/resistant

,$ Methicillin Intermediate S.aureus 2 M:DSA 3

MI! o;acillin + & < * =g>ml Due to production of 4B4 & % * ? @



!hildren5s and Maternity “ Harapan Kita “ Hospital%!hildren5s and Maternity “ Harapan Kita “ Hospital%

anuary / December *--@anuary / December *--@

ARDSARDS hird class pediatric 6ardhird class pediatric 6ard 4I!C4I!C

#irst class pediatric 6ard#irst class pediatric 6ard "I!C> LEL II"I!C> LEL II Second class pediatric 6ardSecond class pediatric 6ard EI4 class pediatric 6ardEI4 class pediatric 6ard ransitional neonatal 6ardransitional neonatal 6ard Surgical pediatric 6ardSurgical pediatric 6ard

////////////////////////////////////////////////////////////////////////////////////////////////////

FF In patientsIn patients

FF:ut patients:ut patients

4:SIIE4:SIIE

,& 2 ,0$@G 3,& 2 ,0$@G 3

' 2 &-$.G 3' 2 &-$.G 3

0 2 .$@G 30 2 .$@G 30 2 .$@G 30 2 .$@G 3

0 2 .$@G 30 2 .$@G 3

* 2 *$@G 3* 2 *$@G 3

* 2 *$@G 3* 2 *$@G 3

& 2 &%*G 3& 2 &%*G 3

////////////////////////////////////////////////////////////////////////////////////////////////////

FF 2 0'%(G 3 2 0'%(G 3

FF &0 2 *-%(G 3&0 2 *-%(G 3



MRSA isolates from ., 7arious clinical specimensMRSA isolates from ., 7arious clinical specimens

at !hildren5s and Maternity “ Harapan Kita “at !hildren5s and Maternity “ Harapan Kita “

Hospital anuary / December *--@Hospital anuary / December *--@

SpecimensSpecimens StoolsStools CrinesCrines

BloodBlood hroat s6abhroat s6ab ndotracheal tubesndotracheal tubes Bronchial dischargeBronchial discharge 4eritoneal la7age4eritoneal la7age "ec abcess"ec abcess

//////////////////////////////////////////////////////////////// otalotal

4ositi7e4ositi7e

@- 2 @.$*G 3@- 2 @.$*G 3

*@ 2 *'G 3*@ 2 *'G 3

' 2 &-$.G 3' 2 &-$.G 3 @ 2 @$.G 3@ 2 @$.G 3

* 2 *$@G 3* 2 *$@G 3

* 2 *$@G 3* 2 *$@G 3

& 2 &$*G 3& 2 &$*G 3

& 2 &$*G 3& 2 &$*G 3

//////////////////////////////////////////////////////////////////////////////

., 2 &-- G 3., 2 &-- G 3



usceptibilit" Pattern of M-' . +1 / 0 to )onBetausceptibilit" Pattern of M-' . +1 / 0 to )onBeta

2actam 'gents in2actam 'gents in PIC%3)IC%PIC%3)IC% C*ildren4s and Maternit" C*ildren4s and Maternit"

5 arapan 7ita 5 ospital, #anuar" 8 ecember +!!5 arapan 7ita 5 ospital, #anuar" 8 ecember +!!



Proportion of isolates associated it* aProportion of isolates associated it* a

nosocomial infection among IC% or nonIC%nosocomial infection among IC% or nonIC%

patients *o ere M-'patients *o ere M-'

P e r c e n t R e s i s t a

n c e



rends of MRSA and bacteremiarends of MRSA and bacteremia

MRSA in !hildren5s and MaternityMRSA in !hildren5s and Maternity

“ Harapan Kita “ Hospital“ Harapan Kita “ Hospital



MRSA

Spread bet6een hospital by mo7ement ofcolonised or infected patients and staff

:ften multiple resistant

Eancomycin or eicoplanin / “drug ofchoiceJ

Sepsis occurs in ( /-G of this colonised/// more fre9uently in I!C or surgicalpatients 2 Da7id ilis 3



Ris factors for ac9uiring MRSA

4rolonged hospitalisation

4rior antimicrobial therapy

Se7ere underlying disease

;posure to other infected or colonised

indi7iduals

:ld age

In7asi7e procedures



!D! recommendation for isolation of patients

6ith MRSA infection or coloniation

Cse of contact precautions% include +

Hand6ashing

Routine use of non/sterile glo7es

"on/sterile go6ns are recommended if

contamination of clothing 6ith body fluids is liely to

occur

4atients care e9uipment and the en7ironment need

to be appropriately cleaned

A single room 2 or a system of cohorting 3 and limited

transport of the patient from the room



Measures to monitor the

fre9uency of MRSA infection

&$ !ollecting nasal 2 or nasal and rectal 3 culturesprior to admission from any patient pre7iouslydocumented to ha7e had MRSA infection or

coloniation or 6ho is being transferred froman institution 6here MRSA is pre7alent

*$ Re7ie6ing microbiology records to identifyne6 cases of MRSA infection or coloniation

,$ Maintaining a list of infected or coloniedpatients

@$ Maring these patients medical records toindicate that they are infected or colonied



In outbrea situations

!ulture the nares of health care 6orers 6hoha7e been contact 6ith MRSA infected orcolonied patients

Cse of mupirocin to eliminate carriage inH!5s and patients is also done in selectedsituations

Increasing emphasis has recently been placedon the en7ironment as a potential source forcontamination of a H!5s hands

Limitation on the use of broad spectrumantimicrobials



Screening for MRSA

Since MRSA is endemic% there isno necessity to conduct routinescreening for MRSA carriagee;cept for patients undergoingrenal dialysis program

A patient is deemed non infectiousupon completion of ade9uateappropriate antimicrobial therapy



!riteria for isolation

MRSA pneumonia patients 6hoha7e not completed appropriate

antimicrobial therapy

MRSA 6ounds that can not beade9uately co7ered 6ith sealed

dressing

;foliati7e dermatitis patients 6ith

MRSA isolated on sin



EISA or ERSA

EISA +

MI! Eancomycin + . =g>ml

#irst reported in apan% &'' Due to prolonged intermittent use of

7ancomycin in the treatment of MRSA

4re7ention +

4rudent use of 7ancomycin !ontact precautions to pre7ent

transmission of organisms from person toperson



ER 2 Eancomycin Resistant nterococcus 3

-nterococcus spp. + "ormal flora of gastro/intestinal ?

genito/urinary tracts

#irst reported in #rance% &'. CSA + &'.'

Most of the isolates CSA + -.faecium ?urope + -.faecalis

Spread of ER in hospitals in7ol7es + 4atient/patient transfer !ontaminated e9uipment ransmission through the food chain



Mechanism Resistance of ER

Ac9uisition of a series no7el genes 2 an/an0 anC an" 3 enable the bacteriumto build a ne6 cell that no longer containsthe binding site for 7ancomycin

In urope% due to of administration ofa7oparcin as a feed additi7e in animalhusbandry 2 pig ? chicen 3

In "orth America% due to the hea7y use of7ancomycin

he genetic transfer of resistance due toplasmids and transposons



reatment :ptions of ER

eicoplanin + an0 strains

!ombination of glycopeptide

aminoglycoside

!hloramphenicol + an/ -.faecium

Nuinupristin>dalfopristin + not acti7eagainst -.faecalis

CI + nitrofurantoin or 9uinolones



4roportion of isolates associated 6ith a nosocomial

infection among I!C or non/I!C patients 6ho 6ere ER

Percen

tResistance





4re7ention ? !ontrol of

ER

&$ 4rudent 7ancomycin use

*$ ducational programmes

epidemiology of ER ? its impact onpatient outcome and cost

,$ Laboratory sur7eillance antibioticsusceptibility on enterococci from allspecimen sources 2 especially fromI!Cs% oncology or transplant 6ards 3

@$ 4olicy



4re7ention ? !ontrol of ER 2cont$3

@$ 4olicy +

"otify appropriate staff promptly

Isolate or cohort colonied > infected patients%institute !ontact 4recautions and reinforcehand6ashing practices

Screen patients 2 rectal s6ab or stool culture 3 6hoshare a room 6ith colonied > infected patients

Remo7e patients from Isolation 4recautions afterat least , consecuti7e negati7e cultures frommultiple body sites taen at least & 6ee apart

#lag records of colonied > infected



SBL

2 ;tended Spectrum Beta/

Lactamase 3

4lasmid/mediated 8/lactamasesderi7ed from M /& or M /*and SHE /& enymes

4roduced by nterobacteriaceae%predominantly 1lesiella speciesand -.coli

Inacti7ated by 8/lactamasesinhibitors such as cla7ulanicacid% sulbactam% or taobactam



Arise from mutations of a singleArise from mutations of a singleamino acid substitution in anamino acid substitution in ane;isting enymee;isting enyme due todue to

selected pressure of ,selected pressure of ,rdrd gen$gen$cephs$cephs$

#irst reported in Oermany% &'.,#irst reported in Oermany% &'.,no6 endemic 6orld6ideno6 endemic 6orld6ide

Drug of choice + carbapenemDrug of choice + carbapenem

SBLSBL 2cont$32cont$3



!onse9uences of resistance to

third/generation cephalosporins

,,rdrd OenerationOeneration

!ephalosporins!ephalosporins

:7er/use:7er/use

Klebsiella spp. / E.coli

With ESBL Enterococcus spp.

ResistanceNo coverage

Carbapenem Vancomycin

Overgrowth

Seection

Acinetobacter spp. !"ngi# yeastVRE



4roportion of isolates associated 6ith a

nosocomial infection among I!C or non/I!C

patients 6ho 6ere SBL41.pneumoniae

Percen

tResis t

ance



Ris #actors of !oloniation

or Infection ith SBL4

4lacement of intra7ascular catheters 2 central 7enous4lacement of intra7ascular catheters 2 central 7enouscatheter% arterial catheter 3 or a urinary catheter catheter% arterial catheter 3 or a urinary catheter

mergency intra/abdominal surgerymergency intra/abdominal surgery

Oastrostomy or PePunostomy tube placementOastrostomy or PePunostomy tube placement

Oastrointestinal coloniationOastrointestinal coloniation

Length of hospital or intensi7e care unit stayLength of hospital or intensi7e care unit stay

4re7ious antibiotics 2 including third/generation4re7ious antibiotics 2 including third/generationcephalosporins 3cephalosporins 3

Se7erity of illnessSe7erity of illness

Eentilator assistanceEentilator assistance



4attern of SBL4 2 &G 3 from !linical

Specimens in 4I!C>"I!C !hildren5s and Maternity

“ Harapan Kita “ Hospital% uly < December *--*

N$C%P$C%



Susceptibility 4attern of SBL4 2 G 3 to Beta/Lactam

Agents in 4I!C !hildren5s and Maternity


Latre# &''&



Susceptibility 4attern of SBL4 2 G 3 to "on/Beta/

Lactam Agents in 4I!C !hildren5s and Maternity


Latre# &''&



!haracteristic of SBL4 in 4I!C>"I!C

!hildren5s and Maternity “ Harapan Kita “

Hospital% uly < December *--*

ards +

4I!C + @ G "I!C + , G

Mortality + *@ G

Latre# &''&



4re7ention and !ontrol of4re7ention and !ontrol of

SBLSBL

:nce SBL4 in7ade a hospital%:nce SBL4 in7ade a hospital%it is difficult to eradicate themit is difficult to eradicate them

Restriction of ,Restriction of ,rdrd gen$ cephs$gen$ cephs$monotherapy 2 antibiotic cycling 3monotherapy 2 antibiotic cycling 3

!ontact 4recautions!ontact 4recautions

Antibiotic 4olicy 2 including De/Antibiotic 4olicy 2 including De/escalation herapy 3escalation herapy 3



Antimicrobial Resistance+

Key 4re7ention Strategies

OptimizeUse

Prevent Transmission Prevent Infection

Effective Diagnosis and Treatmen

4athogenAntimicrobial-Resistant Pathogen

Antimicrobial Resistance

Antimicrobial Cse

Infection

Susceptible Pathogen



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Emerging Infection ( Dr. Latre Buntaran,Spmk )