Multidrug-resistant Organisms (MDROs): Is the Future to be Feared? Multi-drug Resistant Organisms (MDROs)

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1 Multidrug-resistant Organisms (MDROs): Is the Future to be Feared? North Carolina Center for Hospital Quality and Patient Safety October 17, 2013 Cary, North Carolina William R. Jarvis, M.D. Jason and Jarvis Associates, LLC Multi-drug Resistant Organisms (MDROs) Bacteria that acquire the ability to resist treatment against more than one antibiotic. Infections caused by MDRO: More difficult to treat; require more toxic antibiotics Often result in poor patient outcomes Cost more. MDRO are readily transmitted in healthcare settings. 1

2 Major Healthcare-associated Infection Pathogens Methicillin-resistant Staphylococcus aureus (MRSA) Vancomycin-resistant Enterococcus spp. (VRE) ESBL (Extended-spectrum Beta-lactamase) producing Enterobacteriaceae (Klebsiella spp., E. coli) (ESBL-producing Gramnegative bacteria) AmpC producing Enterobacter spp. and Serratia spp. Resistant Pseudomonas aeruginosa Resistant Acinetobacter baumanni KPC producing Klebsiella pneumoniae (CRE) Staphylococcus aureus ~ 20% of humans are persistently colonized (children > adults); ~ 60% are intermittently colonized Most often spread via contaminated hands 2

3 Methicillin-Resistant S. aureus (MRSA) Resistant to beta-lactam antibiotics (all penicillins and cephalosporins) Identified based on antimicrobial susceptibility testing MRSA Clinical Spectrum Severe / Invasive Infections Skin Infections Colonization 3

4 Types of MRSA Community associated (CA-MRSA) Skin infections common No recent hospitalization, dialysis, surgery, LTCF residence Susceptible to most antibiotics except beta-lactams and erythromycin Healthcare-associated (HA-MRSA) Causes nosocomial pneumonia, surgical wound, and bloodstream infections Risk factors: hospitalization, LTCF resident, dialysis, surgery Resistant to many antimicrobials Carbapenem-Resistant Enterobacteriaceae (CRE) 4

5 Carbapenems Class of antibiotics Mainstay of treatment targeting resistant Gramnegative bacilli Ertapenem, imipenem, meropenem, doripenem Enterobacteriaceae Large family of Gram-negative bacteria Common species Klebsiella pneumoniae Escherichia coli Enterobacter cloacae Enterobacter aerogenes 5

6 Carbapenem-Resistant Enterobacteriaceae (CRE) Resistant to 3 classes of antibiotics, including carbapenems Resistance mechanisms Enzymes that inactivate carbapenems Klebsiella pneumoniae carbapenemase (KPC) New Delhi Metallo β-lactamase (NDM-1) Located on chromosomes or plasmids (mobile genetic elements) What kinds of infections do CREs cause? Urinary tract, intestinal or abdominal, respiratory tract, and wound infections Most frequently isolated from urine, sputum, or blood Bloodstream infections are associated with higher rates of death than infection at other sites Patel JB. Presented at 107th ASM General Meeting, 2007 Agmon O. Presented at 8th Congress of IFIC

7 Who is at increased risk for infection with CREs? Hospitalized patients with: Co-morbid conditions Frequent or prolonged hospitalization Invasive devices Antimicrobial exposure (vancomycin, fluoroquinolones, penicillins, and extended-spectrum cephalosporins) Esther T. Tan, et al. CID. Submitted Clostridium difficile 7

8 C. difficile Named due to difficulty to isolate in the laboratory (Latin difficile = difficult) Spore-forming, anaerobic, gram-positive bacillus Fecal-oral transmission Hands of healthcare personnel Contaminated inanimate objects Two major reservoirs: Infected humans (symptomatic or colonized) Inanimate objects CDC Fact Sheet, 2005 Simor ICHE, 2002 C. difficile Infection (CDI) Facts Hospital stays from C. difficile infections tripled in the last decade, posing a patient safety threat especially harmful to older Americans. Almost all C. difficile infections are connected to getting medical care. Hospitals following infection control recommendations lowered C. difficile infection rates by 20% in <2 years. CDC. 8

9 Risk Factors for C. difficile Infection Antimicrobial exposure Acquisition of C. difficile Advanced age Underlying illness Immunosuppression Tube feeds Gastric acid suppression Use of nasogastric or gastrostomy feeding tubes Use of proton-pump inhibitors Main modifiable risk factors CDI and Antibiotic Use > 90% cases occur during or after antibiotic therapy All antibiotics implicated; Broad spectrum agents are more likely associated 9

10 Clinical Manifestations of CDI Asymptomatic colonization Asymptomatic colonization may be protective against CDI Fever SHEA and IDSA Guidelines, 2007 Diarrheal illness Cramping abdominal pain Increased frequency of loose, watery, unformed bowel movements not due to another cause Recent history of antibiotic exposure Pseudomembranous colitis Toxic megacolon New Epidemic Strain of C. difficile BI/NAP/027 Increased Toxin Production Fluoroquinolone Resistance Severe Clinical Disease Severity of Clostridium difficile infection is increasing 10

11 Antimicrobial Resistance Among Gram-positive Healthcare-associated Infection Pathogens, by ICU Status Methicillin-resistant S. aureus Methicillin-resistant Coagulase-negative Staphylococci ICU Patients Non-ICU Patients Vancomycin-resistant enterococci Source: NNIS DATA Clinics Chest Med. 20: Antimicrobial Resistance Among Select Gram-negative Healthcare-associated Infection Pathogens, by ICU Status P. aeruginosa resistant to quinolones P. aeruginosa resistant to imipenem ICU Patients Non-ICU Patients K. pneumoniae non-susceptible to 3rd cephalosporins Source: NNIS DATA Clinics Chest Med. 20:

12 NNIS Summary 2004 Fig 1. Selected antimicrobial-resistant pathogens associated with nosocomial infections in ICU patients, comparison of resistance rates from January through December 2003 with 1998 through 2002, NNIS System. CNS, Coagulase-negative staphylococci; 3rd Ceph, resistance to 3rd generation cephalosporins (either ceftriaxone, cefotaxime, or ceftazidime); Quinolone, resistance to either ciprofoxacin or ofloxacin. Percent (%) increase in resistance rate of current year (January- December 2003) compared with mean rate of resistance over previous 5 years ( ): [(2003 rate previous 5-year mean rate)/previous 5-year mean rate] 100. American Journal of Infection Control Volume 32, Issue 8, December 2004, Pages Importance as Viewed by National and International Health Agencies FDA: Unless antibiotic resistance problems are detected as they emerge, and actions are taken to contain them, the world could be faced with previously treatable diseases that have again become untreatable, as in the days before antibiotics were developed. --- the so-called post-antibiotic era WHO: antimicrobial resistance is a global problem that must be addressed in all countries. No single nation, however effective it is at containing resistance within its borders, can protect itself from the importation of resistant pathogens through travel and trade. 12

13 Shifting Paradigm on Healthcare-associated Infections Many infections are inevitable, although some can be prevented (Acceptance) Each infection is potentially preventable unless proven otherwise (Zero Tolerance) Jarvis WR. J Hosp Infect. 2007;65 Suppl 2:3-9. Mortality associated with Antimicrobial Resistance 14,000-63,000 people die in the United States annually as a result of resistant healthcare-associated infections* Thousands more die each year from resistant infections acquired in the community. * World Health Organization (WHO). Overcoming antimicrobial resistance, World Health Organization report on infectious diseases. Geneva:WHO, Centers for Disease Control and Prevention. Workshop Summary. Knobler, S. L., S. M. Lemon, et al. (eds.) Washington DC: National Academies Press,

14 U.S. Costs Associated with Antimicrobial Resistance Outpatient infections: $400 million $16.5 billion annually. Hospital infections: $4-5 million dollars annually. * Elbasha E. Deadweight loss of bacterial resistance due to overtreatment. Atlanta Mimeo 1999; ** Institute of Medicine. Microbial threats to health: emergence, detection, and response. Washington, DC: National Academies Press, How Do Antimicrobial-resistant Pathogens Emerge? 1. Antimicrobial use 2. Failure to properly implement infection control practices 14

15 Factors Contributing to Increased Antimicrobial Resistance Sicker inpatient population Larger immunocompromised population New and more invasive procedures and instrumentation Complacency regarding antimicrobial use Ineffective infection control and compliance Increased antibiotic use Economic Impact of Antimicrobial Resistance Antimicrobials account for upwards of 30% of formulary budgets 50% of antimicrobial usage is inappropriate Clinical Condition LOS Attributable Cost MRSA in ICU 1 $9,275 MRSA vs. MSSA bacteremia 2 9 vs. 7 d $7,212 MRSA vs. MSSA SSI 3 $13,901 Emergence of resistant Pseudomonas 4 OR 1.7 Enterobacter resistant to 3rd gen ceph 5 OR 1.47 $29,379 MDR-Acinetobacter vs more days $3,758 non-mdr Acinetobacter bacteremia 6 MDR-Acinetobacter in burn unit 7 $98,575 Annual cost of infections due to antimicrobial resistant bacteria estimated to be $4 to $5 billion (IOM 1998) 1 JAMA 1999;282: Arch Intern Med 2002;162: ICHE 2005;26: ICHE 2007;28: Clin Infect Dis 2003;36: Am J Infect Control 2004;32: Arch Intern Med 1999;159:

16 10/15/13 Clinical Impact of Resistance Increasing resistance Inpatient (MRSA, VRE, Pseudomonas, Acinetobacter) Outpatient (E. coli, CA-MRSA, S. pneumoniae) Clinical Condition Mortality Risk MRSA vs. MSSA bacteremia MRSA vs. MSSA SSI2 3.4 VRE vs. VSE bacteremia Emergence of resistant Pseudomonas4 3.0 Enterobacter resistant to 3rd gen ceph MDR-Acinetobacter vs. non-mdr Acin bacteremia Clin 4Arch 2Clin 5Arch Intern Med 1999;159: Intern Med 2002;162: Infect Control Hosp Epidemiol 2007;28:713-9 Infect Dis 2003;36:53-9 Infect Dis 2003;36: Clin Infect Dis 2005;41: SSI: surgical site infection CLABSI: central line-associated bloodstream infection VAP: ventilator-associated pneumonia CAUTI: catheter-associated urinary tract infection Source: CDC 16

17 Why MRSA? Overall, Staphylococcus aureus is the second most common healthcare-associated infection (HAI) pathogen (coagulase-negative Staphylococcus is #1) S. aureus is #1 for VAP and SSI. On average, in hospitalized patients, of all S. aureus-hais, MRSA accounts for ~50%. MRSA is the most common antimicrobial-resistant pathogen reported at CDC National Healthcare Safety Network (NHSN) hospitals (and at most hospitals worldwide). AJIC 2005;32:482; ICHE 2008:29: MRSA Colonization Leads to Infection " Nares cultures on all patients admitted to five units. " 30/758 (3.96%) patients MRSA-colonized on admission. " 19% of those MRSA-colonized on admission and 25% of those acquiring MRSA in the hospital developed MRSA infections compared to 1.5% of those MSSAcolonized or 2% of those not colonized. " MRSA-colonization increased infection risk compared to MSSA-colonization (RR=9.5) or un-colonized (RR=12). " Identifying MRSA-colonized patients at admission may benefit from interventions to decrease infection. Davis et al CID 2004;39:

18 Risk of MRSA Infection and Death in Longterm MRSA Carriers " Study design: Follow-up of 281 prevalent (>1 yr) MRSA carriers. " Results: 65/281 developed 96 discrete and unrelated MRSA infections within 1 year. " Pneumonia 39% " Soft tissue 14% " CVC-infections 14% " BSI 24% 38 MRSA infections occurred during new hospital admissions. 32 (84%) were the reason for the admission. 14 deaths occurred; 22% of MRSA infections and 5% of colonized patients. 35 Datta R et al., CID 2008;47: Can t You Just Rely On Clinical Cultures To Detect MRSA-Patients? " Muder et al. showed that in a VA Hospital Surgical Unit from November 2001-August 2002, when they performed AST (cultures) on all admitted patients, only 33/91 (36%) with MRSApositive cultures would have been detected by clinical cultures. (Muder et al, SHEA Annual Meeting 2004; Muder RR et al. ICHE 2008;29:702-8;). " Salgado et al. found that of 437 patients MRSA-colonized on hospital admission, only 66 (15%) had positive clinical cultures for MRSA during their hospital stay. (Infect Control Hosp Epidemiol. 2006;27:116-21). " Muto et al found that only 26% (118/459) of the 459 patients identified as MRSA-colonized via AST had a MRSA + clinical culture; ¾ of all patients would have been missed if AST were not in place. (Muto et al, SHEA Annual Meeting 2005). " Kurup et al. found that 11 times more MRSA was detected with active surveillance testing than with clinical cultures in ICU patients. AJIC 2010;38:

19 Methods for MRSA Surveillance Active Surveillance Testing (AST) " Active surveillance testing for MRSA can be defined as performing diagnostic testing for the purpose of detecting asymptomatic MRSA colonization. " Involves collection of superficial swab specimens from >1 common sites of MRSA colonization. " Tests specimens for the presence of MRSA using bacterial culture techniques or other methodologies. " Detects a large proportion of the MRSA-colonized persons within a hospital who otherwise would go undetected. " Identifies patients who are already colonized at the time of admission so that subsequent MRSA isolates are not falsely attributed to intra-facility acquisition. " May more accurately monitor MRSA transmission and effectiveness of prevention programs than monitoring of clinical specimens alone. " Multiple published reports have shown an association between active surveillance testing and control of MRSA when such testing was included as part of a comprehensive MRSA prevention program. Calfee D. et al, ICHE 2008;29:S U.S. MRSA Hospitalizations " From , MRSA hospitalizations increased from ~45/100,000 population to ~115/100,000 population (Zilberberg M et al. EID 2008;14:1756-8). 2.6 fold increase " From , MRSA-related U.S. hospitalizations increased from 127,036 to 278,203 (Klein E et al. EID 2007;13:1840-6). 2-fold increase 38 19

20 Invasive MRSA Infections in the United States, ,987 cases of invasive MRSA (July December 2005). HA-MRSA: 7,639 (85%), CA-MRSA 1,234 (13.7%), 114 (1.3%) not classified. 5,287 invasive MRSA infections in When standardized for the U.S. population, it was estimated that in 2005: 94,360 patients had invasive MRSA infections 18,650 (19.76%) in-hospital deaths from invasive MRSA. Klevens RM et al. JAMA 2007;298: Healthcare Associated Invasive MRSA Infections, Kallen A., et al. JAMA 2010;304:

21 MRSA Prevention Recommendations Muto CA. et al, ICHE 2003;24: Calfee D. et al, ICHE 2008;29:S CDC Management of Multidrug-resistant Organisms (MDROs) in Healthcare Settings ( pdf/ar/mdroguideline2006.pdf). Recommendations For Preventing MRSA Transmission-Active Detection and Isolation (ADI) 1. Risk assessment to identify high risk patients. 2. Active surveillance testing of identified high-risk populations to identify the reservoir for spread. 3. Hand hygiene. 4. Barrier precautions for patients known or suspected to be colonized or infected with epidemiologically important antimicrobial-resistant pathogens, such as MRSA or VRE. 5. Decolonization or suppression of colonized patients (esp. in surgical patients). 6. Antibiotic Stewardship. Muto CA. et al, ICHE 2003;24:

22 Interventions Controlling Endemic MRSA " Study Design: Retrospective study of 4 major infection control interventions promoting compliance with: 1) maximum barrier precautions; 2) institution of alcohol-based hand rubs for hand disinfection; 3) hand hygiene campaign; and 4) institution of routine nares cultures for MRSA in all ICU patients on admission and weekly thereafter (+ cult contact isolation). Four years. Eight ICUs. " Analysis: Interrupted time series. Huang SS. et al. CID 2006:43:

23 Controlling Endemic MRSA " Results: In 16 months of active surveillance cultures for MRSA, the incidence density of MRSA-BSI decreased by 75% in the ICUs (P=.007) and by 40% in non-icus (P=.008), leading to a 67% hospital-wide reduction in the incidence of MRSA-BSI (P=.002). MSSA rates remained stable. The other interventions were not associated with a statistically significant change in MRSA-BSIs. " Conclusion: Routine surveillance for MRSA in ICUs allowed earlier initiation of contact isolation precautions and was associated with a large and statistically significant reduction in MRSA-BSI in the ICUs and hospital-wide. No similar decrease was attributable to the other infection control interventions including hand hygiene and contact isolation Impact of a 4-Year Universal Surveillance and Decolonization Program to Control Methicillin- Resistant Staphylococcus aureus (MRSA) The rate of total clinical S. aureus (20.2 to 13.4/1,000 admissions) and MRSA (10.4 to 4.1/1,000 admissions) (P 0.001), but MSSA did not change. The prevalence density of aggregate hospital-associated MRSA disease (all body sites) at baseline, during ICU surveillance, and during universal surveillance was 8.9, 7.4 (P = 0.15 compared with baseline), and 3.3 (P compared with baseline and ICU surveillance), respectively. The prevalence density of MRSA infection at each body site decreased. The percentage of exogenous MRSA fell from 48.1% to 33.3%. This intervention was estimated to reduce healthcare infection cost by almost $9 million and prevented 72 deaths. Robicsek et al., Annals Intern Med

24 ~ 70% reduction in MRSA-HAIs Robicsek et al., Annals Intern Med 2008 On average: 16 hour TAT from collection to result 47 Impact of a 4-Year Universal Surveillance and Decolonization Program to Control Methicillin- Resistant Staphylococcus aureus (MRSA) Conclusions: The introduction of universal admission surveillance for MRSA was associated with a large and progressive reduction in MRSA disease during admission and 30 days after discharge that was sustained for 4 years. It also reduced total S. aureus infections due to reduction in MRSA disease, global healthcare cost, and mortality. Robicsek et al., Annals Intern Med

25 Original Article Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus (MRSA) Infections Rajiv Jain, M.D., Stephen M. Kralovic, M.D., M.P.H., Martin E. Evans, M.D., Meredith Ambrose, M.H.A., Loretta A. Simbartl, M.S., D. Scott Obrosky, M.S., Marta L. Render, M.D., Ron W. Freyberg, M.S., John A. Jernigan, M.D., Robert R. Muder, M.D., LaToya J. Miller, M.P.H., and Gary A. Roselle, M.D. N Engl J Med 2011;364: The Veteran s Hospital Administration (VHA) MRSA Control Program The national initiative focuses on implementing the VHA MRSA Bundle which consists of four essential elements (Active Detection and Isolation or ADI): 1. Active Surveillance Testing: Admission/Transfer/Discharge 2. Hand Hygiene 3. Contact Precautions 4. Cultural Transformation (Leadership and Staff Engagement). Phase I: The VHA system began doing universal patient testing in 2006 at its approximately 150 hospitals in ICU patients. Phase II of the initiative began in March 2007 and was a national rollout including all VHA medical facilities with all patients (ICU and non- ICU). MRSA prevalence on admission ranged from 5% to 22% (clinical culture 1-1.5%; AST 9%-12%). 25

26 Active Surveillance Testing for MRSA among Patients Admitted to and Those Transferred or Discharged from Acute Care Veterans Affairs (VA) Medical Units Nationwide. Jain R et al. N Engl J Med 2011;364: Mean National Prevalence of MRSA at the Time of Admission to Veterans Affairs (VA) Medical Centers. Jain R et al. N Engl J Med 2011;364:

27 Nationwide Rates of Health Care Associated Infections with MRSA in Veterans Affairs (VA) Facilities. Jain R et al. N Engl J Med 2011;364: Nationwide Monthly Rates of Ventilator-Associated Pneumonias and Central Venous Catheter Associated Bloodstream Infections with MRSA in Veterans Affairs Intensive Care Units. Jain R et al. N Engl J Med 2011;364:

28 55 Conclusions A program of universal active, MRSA surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a significant decrease in health care associated transmissions of and infections with MRSA in a large healthcare system. 28

29 Mandatory Implementation of MRSA Control Measures Joint Commission 2009 National Patient Safety Goal 29

30 The Emergence of VRE Implications of vancomycin-resistance Limited conventional therapies Potential transfer of resistance to Staphylococcus aureus (to date, 3 such VRSA patients) Rise in vancomycin-resistance of enterococci hospital-wide data: >40-fold increase* ICU data: >60-fold increase* Accounts for >25% of ICU-acquired enterococcal infections Endemic in many hospitals *Source: National Nosocomial Infections Surveillance (NNIS) System. Siouxland District First VRE isolate in December 1996 April 1997 >60 VRE isolates over 4 months SOUTH DAKOTA Rapid City Akron Emerson IOWA NEBRASKA Sioux City Des Moines Omaha Sioux City Onawa Kingsley Mapleton Des Moines 30

31 Background of VRE in Siouxland December April 1997: 3 to 58 isolates Siouxland District Health Department organized the healthcare community response to VRE with regional infection control personnel The Siouxland VRE Task Force recommendations for screening, infection control, and education programs Hospital Infections Program, CDC assistance determine VRE prevalence rates Background of VRE in Siouxland Culture of BLAME. Siouxland District Health Department Organized the healthcare community response Formed the Siouxland VRE Task Force CDC assistance Conduct VRE prevalence surveys Investigate factors associated with VRE spread Identify and assist in implementation of infection control strategies 31

32 Describing the Problem Conduct prevalence survey 40 colonized patients/residents identified Case-control study of risk factors associated with VRE colonization Antimicrobial use Recent hospitalization Develop a prevention program Case Control Study 1997 Acute Care Facilities LTCF Longer length of stay Receipt of antimicrobial agent (vancomycin or cephalosporins) Admitted to an Acute Care Facility, esp. Facility A 32

33 VRE Prevention Program VRE Task Force Recommendations Screening asymptomatic individuals for VRE Culturing on admission and/or discharge Isolation/cohorting precautions Barrier precautions, hand hygiene Infection control/vre education Staff, patients, families VRE Prevalence in 30 Healthcare Facilities, Siouxland, 1997 vs

34 Molecular Epidemiology in VRE-Positive Patients and Residents WHAT CAN WE DO TO CONTROL MRSA AND VRE? No Screening VRE Screening 34

35 The inanimate environment is a reservoir of pathogens X represents a positive Enterococcus culture The pathogens are ubiquitous ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. CDC Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE) CRE are defined as Enterobacteriaceae that are: Non-susceptible to one of the following carbapenems: doripenem, meropenem, or imipenem; Resistant to all of the following third-generation cephalosporins that were tested: ceftriaxone, cefotaxime, and ceftazidime; Klebsiella spp. and Escherichia coli that meet the CRE definition are a priority for detection and containment; however, other Enterobacteriaceae might also be important in some regions; For bacteria that have intrinsic imipenem non-susceptibility (i.e., Morganella morganii, Proteus spp., Providencia spp.), requiring nonsusceptibility to carbapenems other than imipenem as part of the definition might increase specificity; and This CRE surveillance definition is based upon the current (M100- S ) Clinical and Laboratory Standards Institute (CLSI) interpretative criteria (breakpoints) for carbapenem susceptibility among Enterobacteriaceae. 35

36 CDC Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE) CRE have been associated with high mortality rates (up to 40 to 50% in some studies). In addition to β-lactam/carbapenem resistance, CRE often carry genes that confer high levels of resistance to many other antimicrobials, often leaving very limited therapeutic options. Panresistant KPC-producing strains have been reported. CRE have spread throughout many parts of the United States and have the potential to spread more widely. CDC Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE)--Core Measures for All Acute Care Facilities 1. Hand hygiene Promote hand hygiene Monitor hand hygiene adherence and provide feedback Ensure access to hand hygiene stations 2. Contact Precautions Place CRE colonized or infected patients on Contact Precautions (CP) Preemptive CP might be used for patients transferred from high-risk settings Educate healthcare personnel about CP Monitor CP adherence and provide feedback No recommendation can be made for discontinuation of CP Develop lab protocols for notifying clinicians and IP about potential CRE 36

37 CDC Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE)--Core Measures for All Acute Care Facilities 3. Patient and staff cohorting l When available cohort CRE colonized or infected patients and the staff that care for them even if patients are housed in single rooms l If the number of single patient rooms is limited, reserve these rooms for patients with highest risk for transmission (e.g., incontinence) 4. Minimize use of invasive devices 5. Promote antimicrobial stewardship 6. Screening l Screen patient with epidemiologic links to unrecognized CRE colonized or infected patients and/or conduct point prevalence surveys of units containing unrecognized CRE patients CDC Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE)--Supplemental Measures for Healthcare Facilities with CRE Transmission 1. Conduct active surveillance testing Screen high-risk patients at admission or at admission and periodically during their facility stay for CRE. Preemptive CP can be used while results of admission surveillance testing are pending Consider screening patients transferred from facilities known to have CRE at admission 2. Chlorhexidine bathing Bathe patients with 2% chlorhexidine 37

38 General Approach to Carbapenem-resistant Enterobacteriaceae (CRE) Control in Facilities that Rarely or Have Not Identified CRE New CRE-colonized or CRE-infected patient identified Notify appropriate personnel (i.e., clinical staff, infection prevention staff Notify public health if indicated Place patient on Contact Precautions in single room (if available). Reinforce hand hygiene and use of Contact Precautions on affected ward/unit Educate healthcare personnel about preventing CRE transmission Screen epidemiologically-linked patient contacts (e.g., roommates) for CRE with at least stool, rectal, or peri-rectal cultures and/or consider point prevalence survey of affected unit Consider preemptive Contact Precautions of these patients pending results of screening cultures If screening cultures or further clinical cultures identify additional CREcolonized or -infected patients, consider additional surveillance cultures of contacts or point prevalence surveys of affected units (if not already done). General Approach to Carbapenem-resistant Enterobacteriaceae (CRE) Control in Facilities that Rarely or Have Not Identified CRE Consider cohorting patients and staff. Ensure if patient transferred within the facility that precautions are continued. Ensure if patient transferred to another facility CRE information is shared with accepting facility. Consider cohorting patients and staff. Ensure if patient transferred within the facility that precautions are continued. Ensure if patient transferred to another facility CRE information is shared with accepting facility. 38

39 Targeted versus Universal Decolonization to Prevent ICU Infection Huang S. et al., N Engl J Med 2013; 368: Targeted versus Universal Decolonization to Prevent ICU Infection Huang S. et al., N Engl J Med 2013; 368:

40 Targeted versus Universal Decolonization to Prevent ICU Infection Huang S. et al., N Engl J Med 2013; 368: Targeted versus Universal Decolonization to Prevent ICU Infection Huang S. et al., N Engl J Med 2013; 368:

41 Targeted versus Universal Decolonization to Prevent ICU Infection Huang S. et al., N Engl J Med 2013; 368: Targeted versus Universal Decolonization to Prevent ICU Infection Huang S. et al., N Engl J Med 2013; 368:

42 Prevention and Control of MDRO Transmission Successful control of MDROs has been documented using a variety of combined interventions. These include: - Improvements in hand hygiene; - Use of Contact Precautions until patients are culture-negative for a target MDRO; - Active surveillance cultures/testing; - Education; - Enhanced environmental cleaning; and improvements in communication about patients with MDROs within and between healthcare facilities. Thank You! 42