Multidrug-Resistant Organisms: How Do We Define them? How do We Stop Them?

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1 Multidrug-Resistant Organisms: How Do We Define them? How do We Stop Them? Roberta B. Carey, PhD Centers for Disease Control and Prevention Division of Healthcare Quality Promotion Why worry? MDROs Clinical manifestation same as infections caused by susceptible bacteria but treatment options are extremely limited Increased LOS Increased costs Increases mortality rate Colonization more likely to lead to symptomatic infection (MRSA) Definitions for MDR Pseudomonas and Acinetobacter Source/ Study J Med Micro : 1619 (26) 17 studies 1/-9/ Fr. Natl. Tech. Comm. for Nosocomial Infections Am. Cystic Fibrosis Foundation SENTRY Definition Min: R to 2 classes Med: R to 3 classes Max: R to all but 1 agent tested P. aeruginosa R to 1 of 3 selected agents: ticar, ceftaz, imi P. aeruginosa R to all agents in at least 2 of the following groups: β-lactams, AG, FQ P. aeruginosa R to pip, ceftaz, gent, imi Pandrug-Resistant Pseudomonas Pan-resistance is the convergence of multiple resistance mechanisms Resistant to all 7 classes of antipseudomonal agents Penicillins Cephalosporins Carbapenems Monobactams Quinolones Aminoglycosides Polymyxins

2 HICPAC Definition MDRO Guidelines 26 For epidemiologic purposes, MDROs are defines as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents Names may describe resistance to one agent (VRE, MRSA) but the organisms are often resistant to most available agents Methicillin-Resistant Staphylococcus aureus (MRSA) Among Intensive Care Unit Patients Vancomycin-Resistant Enterococci (VRE) Among Intensive Care Unit Patients rd Generation Cephalosporin-Resistant Klebsiella pneumoniae Among ICU Patients Fluoroquinolone-Resistant Pseudomonas aeruginosa Among ICU Patients Organisms of Concern Methicillin resistant Staphylococcus aureus Vancomycin resistant enterococci MDR Streptococcus pneumoniae ESBL-producing Enterobacteriaceae KPC-producing Enterobacteriaceae Acinetobacter baumannii Pseudomonas aeruginosa Stenotrophomonas maltophilia Burkholderia cepacia Ralstonia pickettii Clostridium difficile

3 One Definition Does Not Fit All Bugs Consider where the bugs are located Consider how the drug will be administered In vitro results may not equal in vivo activity for chronic infections Organisms in biofilms behave differently Traditional MICs don t reflect environment where Pseudomonas lung infection is occurring MDR Acinetobacter NNIS cases of Acinetobacter baumannii infection reported to NNIS 361 isolates had susceptibility data to all 4 classes of antimicrobial agents Β-lactams, AG, FQ, carbapenems NS = I or R to all agents in that class MDR = isolate NS to all 4 classes Acinetobacter Non-Susceptible to the Four Classes of Antimicrobial Agents Trends in Multidrug-Resistant Acinetobacter % Non-susceptible NS to BL NS to AG NS to FQ NS to CA % Non-susceptible NS to 3 classes, S to one NS to all 4 classes MDR Acinetobacter by Geographic Region 6 & above 37% -1 yr % 2-18 yr 1% MED 38% GYN <1% PED <1% yr 62% SURG 61% 74% 1.6% 13% 12% Northeast Midwest South West Multidrug Resistant Acinetobacter Grouped by Age, Service, and Site of Infection SSI 1% Other 2% UTI 11% BSI 13% PNEU 46%

4 P. aeruginosa Non-Susceptible to the Four Classes of Antimicrobial Agents Trends in Non-Susceptible P. aeruginosa 3 Aminoglycosides Fluoroquinolones Carbapenems Beta-lactams 9 NS to 4 NS to % Non Susceptible % Non Susceptible isolates reported to NNIS Merck ICU Surveillance Study (Obritsch AAC 48: 466, 24) MDR Pseudo = R to 3 or more of the following drugs: Ceftaz, cipro, tobra, imi Focus Ortho-McNeil Study (Karlowsky CID 4:S89, 2) MDR Pseudo = R to 3 or more of the following agents: ceftaz, gent, imi, FQ 2394 isolates of P. aeruginosa % pan susceptible 8.9% MDR (7% R to 3 drug, 3% R to all 4 drugs) 14% 4% Vaccines Use local antibiogram Treat infection, not colonization Solutions Target the pathogen Practice hand hygiene Infection control I. Control Intervention Administrative Support Prevention an organizational priority Provide fiscal and human resources Structural upgrades to wash hands Implement systems to communicate about reportable MDROs internally and externally to state/local health dept Provide annual feedback on MDROs to administration and HCWs HICPAC. Management of MDROs in Healthcare Setting, 26

5 II. Control Intervention MDRO Education Facility wide behavior change Prevention strategies and risks Encourage adherence to practice guidelines and infection control practices III. Control Intervention Judicious Use of Antimicrobial Agents Provide annual susceptibility report Review local susceptibility patterns and antimicrobial agents on formulary To guide empiric therapy Implement systems to prompt clinicians to prescribe most appropriate therapy Annually review antibiotic usage IV. Strategies for Influencing Antimicrobial Prescribing Patterns Education Share trends in resistance with clinicians Academic interventions to counteract commercial influences Control antimicrobial usage Formulary restriction Prior-approval programs Automatic stop orders Antimicrobial cycling Removal of redundant antimicrobial combinations Computer-assisted management programs V. Control Intervention MDRO Surveillance Use recommended protocols to detect MDROs Labs must notify ICP when novel resistance pattern observed for that facility Monitor changes in antibiograms MDRO incidence based on culture results MDRO infection rates Molecular typing of MDRO isolates Detect asymptomatic colonization VI. Control Intervention Infection Control Precautions Implement contact precautions for patients colonized/infected with MDROs Masks not required routinely Assign patient with MDROs to single patient room or cohort VII. Control Intervention Environmental Measures Follow recommended cleaning, disinfection, sterilization guidelines Monitor for adherence to recommended environmental cleaning practices Environmental cultures not routinely recommended

6 VIII. Control Intervention Decolonization Limited use for MRSA Not for routine use on patients May be useful to decolonize HCW linked to transmission of MRSA No recommendations for patients with VRE or MDR GNB Why Do We Need Standardized Definitions of MDROs? Understand the magnitude of the problem Talk the same language across institutions and publications Reporting MDROs in NHSN Public reporting of HAI Healthcare Report Card Reimbursement Disclaimer The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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