Time To Regain ControlManagement of Multi-Drug Resistant

Organisms in Healthcare Settings

fiuca@deaconess-cinti.com 513/559-2897

November 2006 – long awaited CDC guidelines released…

• Management of Multi-Drug Resistant Organisms in Healthcare Settings

• Background• Epidemiology• Prevention & Control• Discussion• Recommendations• http://www.cdc.gov/ncidod/dhqp/

pdf/ar/mdroGuideline2006.pdf

II. Background•Definition: microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents•MRSA/VISA/VRSA•VRE•MDR Strep pneumo•ESBLs (E. coli, Kleb)•Problem MDR gnrs•Clinical Importance? – limited options for treating patients

III. Epidemiology

•Trend - ↑, Why?

•Selective pressure from antimicrobials

•CAMRSA

•Poor infection control practices

•Or any combination

•Transmission & Persistence –•Naïve populations•Antimicrobial use•Increased potential due to ↑ #s infected/colonized•Implementation/ adherence to prevention efforts

III. Epidemiology cont.•MDROs are carried from one to another via “dirty ten”•Easily contaminated from patient or environment•Diarrhea patients an issue for those organisms colonizing the GI tract•Not just for acute care setting

•Colonized HCP –•Can become persistently colonized•Limited role in transmission, unless…•Chronic sinusitis•URTI•Dermatitis•Etc

IV. Prevention and Control

• Appropriate clinical practices as a part of ALL routine patient care, ie.,

• Hand hygiene – “When in doubt, wash ‘em out”

• Prompt/accurate diagnosis• Vent bundles• Central Line bundles• SSI bundles• Urinary Catheters• Judicious antimicrobial selection &

utilization, DUEs• Utilization of PPE

Control Interventions

•Administrative Support•Education•Judicious Antimicrobial Use•Surveillance•Infection Control Precautions•Environmental Measures•Decolonization

V. Discussion - Issues

•Impact on other MDROs•Costs•Feasibility•Type & significance of institutional problem•Population & healthcare setting•Differences in opinion on strategies•Two-tiered approach

Recommendations: Tier 1•Administrative Measures:•Patient safety priority•Fiscal & human resources•Expertise•Communication systems•Multidisciplinary process•ID of patients infected or colonized•Community participation•Timely feedback, minimum annually

Recommendations: Tier 1•Education & Training…•Risks & prevention of transmission•Orientation•Periodic updates•Include organizational experiences & strategies

•Judicious Use of Antimicrobials•Multidisciplinary process for use, formulary selection & antibiogram…for hospitals & LTCF•Physician prompts – all healthcare settings•Antibiogram – available for all in facility

Recommendations: Tier 1•Surveillance•Standardized methods in micro lab•Notification from lab•Storage for MDROs… hospitals & LTCF•Facility susceptibility reports•Hospitals/LTCF – special unit reports•Annual & include in lab contract

•Monitor trends – house-wide & unit specific rates using statistical methods•Use this to determine interventions•Establish a baseline or incidence•Evaluate colonization versus infection•Reporting frequency

Recommendations: Tier 1•Precautions:•Standard precautions•Masks – appropriate use•Contact precautions•Acute care: infected or colonized; can modify•LTCF: evaluate pt & situation for infected or colonized; modify•If ill, use Contact

Recommendations: Tier 1• Precautions cont:• Ambulatory Care: standard precautions

with strict adherence to barrier use• Home Care: standard precautions with

strict adherence to barrier use• Limit use of reusable equipment• Appropriate disinfection if can’t leave it• Hemodialysis: “Recommendations to

Prevent Transmission of Infections in Chronic Hemodialysis Patients”

• www.cms.hhs.gov/home/regsguidance.asp

Recommendations: Tier 1

• Discontinuation of precautions: • No recommendation for when!

• Placement - hospitals & LTCF• Private room – prioritize when

limited availability• Cohort same MDRO only• If not possible, place with those at

low risk of acquisition & adverse outcome

Recommendations: Tier 1

•Environmental Measures:•Frequently touched surfaces & equipment cleaned/disinfected•Dedicate non-critical medical items•Prioritize Contact Precautions rooms

Recommendations: Tier 2

• Intensified Interventions• Utilize in various combinations• When?• If incidence/prevalence not ↓• 1st case or outbreak of important

MDRO• Continue to monitor• Add interventions as needed

Recommendations: Tier 2

•Adminstrative•Expertise – design, implementation, evaluation•Leadership, funding, daily oversight•Evaluate health system factors → action plan•Detailed updates

•Educational Interventions•Increase frequency – unit-specific feedback

•Judicious Use of Antimicrobials•Review & control use as indicated

Recommendations: Tier 2• Surveillance• Calculate & Analyze prevalence &

incidence rates for infected & colonized

• Do not use multiple isolates from same patient

• Active Surveillance Cultures (ASC) – develop & implement protocols

• Include areas of skin breakdown & draining wounds including organism specific colonization sites

• At admission & as needed to assess

Recommendations: Tier 2•Surveillance cont.•Conduct serial unit-specific point prevalence surveys to assess progress•Repeat point prevalence cultures at discharge or transfer or other interval•Test roommates•Test HCP if implicated

Recommendations: Tier 2

•Enhanced Infection Control Precautions:•Implement contact precautions until results of ASC are known•Assign dedicated nursing & ancillary personnel•Consider stopping new admissions

•Enhanced Environmental Measures:•Intensify & reinforce training•Monitor adherence to cleaning policies•Environmental cultures, if necessary•Vacate units for thorough cleaning

Recommendations: Tier 2

• Decolonization:• Usually only for MRSA• Consult with experts on case-by-

case basis• If utilize, perform susceptibility

testing• Do not use topical mupirocin

routinely as resistant strains emerge• Only decolonize HCP implicated in

ongoing transmission• Possibly reassign personnel

Thank You…Questions?