Multidrug Resistant OrganismsDanae Bixler, MD, MPH
Objectives• Definitions• Explain:– Which MDROs are important and why– Reservoir for MDROs– Resistance to key antibiotics– ...
Public Health Significance of Multi-Drug Resistancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Increased:...
EXAMPLE – CONTROL OF AVANCOMYCIN-RESISTANTENTEROCOCCUS IN HEALTH CAREFACILITIES IN A REGIONN Engl J Med, 2001; 344:1427-14...
Siouxland region of Iowa, Nebraskaand South DakotaN Engl J Med, 2001; 344:1427-1433• 4 acute care facilities• 28 long term...
Plan: Active SurveillanceN Engl J Med, 2001; 344:1427-1433Acute Care Facilities• Patients transferred fromacute care facil...
Plan: Infection ControlN Engl J Med, 2001; 344:1427-1433Isolation andInfectionControlPrecautionsAcute Care Facility Long T...
Plan: Infection ControlN Engl J Med, 2001; 344:1427-1433Isolation and InfectionControl PrecautionsAcute Care Facility AND ...
Colonization Rates, 1997 – 1999,Siouxland RegionN Engl J Med, 2001; 344:1427-1433Type ofFacilityColonization with VRENumbe...
Prevention Collaborativehttp://www.cdc.gov/hai/recoveryact/stateResources/collaborationPrimer.html• Coordinator• Multidisc...
Prevention Collaborativehttp://www.cdc.gov/hai/recoveryact/stateResources/collaborationPrimer.html• Meetings– Agree on goa...
MDROs Reported to NHSN, 2006-2007Infect Control Hosp Epidemiol, 2008; 29:996-1011Organism Resistant to Number ofisolates t...
MDROs Reported to NHSN, 2006-2007Infect Control Hosp Epidemiol, 2008; 29:996-1011Organism Resistant to Number ofisolates t...
Reservoirs for MDROsOrganism Reservoir Colonizes In hospital environmentStaphylococcusaureusNares, skin Nares, skin Stetho...
Resistance 101Staphylococcus aureusAntibiotic ResistancemechanismLabel Alternate antibioticsPenicillin β – lactamase(induc...
Resistance 101EnterococcusAntibiotic ResistancemechanismLabel AlternateantibioticsAmpicillin Decreased bindingof antibioti...
Resistance 101Gram Negative BacilliAntibiotic ResistancemechanismLabel AlternateantibioticsPenicillins, 1st, 2ndand 3rdgen...
Types of Infections Caused by MDROsGram (+) CocciMandell, 7thEditionBacteria Types of infectionsStaphylococcus aureus •Sur...
Types of Infections Caused by MDROsGram (+) Cocci (2)Mandell, 7thEditionBacteria Types of infectionsEnterococcus species •...
Types of Infections Caused by MDROsGram (-) BacilliMandell, 7thEditionBacteria Types of infectionsPseudomonas aeruginosa •...
Surveillancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Routine clinical cultures (antibiograms)– Detect ...
Surveillancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• MDRO infection rates– Requires clinical data– Hel...
Active Surveillance Cultureshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Prospective identification of col...
EXAMPLE – UNIVERSAL SURVEILLANCEFOR MRSA IN 3 AFFILIATED HOSPITALSAnn Intern Med, 2008; 148:409-418.24
Infection Control StrategiesEvanston Northwestern HealthcareAnn Intern Med, 2008; 148:409-418• 3 hospitals– 40,000 annual ...
Study DesignAnn Intern Med, 2008; 148:409-418Timeframe Period 1 (Aug 1,2003 – July 31,2004)Period 2 (Aug 1,2004 – July 31,...
Ann Intern Med, 2008; 148:409-41827
Infection Control Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Standard precautions– Masks for:...
Infection Control Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Environmental measures– Increase...
EXAMPLE – OUTBREAK OF INFECTIONWITH A MULTIRESISTANT KLEBSIELLAPNEUMONIAE STRAIN ASSOCIATEDWITH CONTAMINATED ROLL BOARDSIN...
Case definitionJ Clin Microbiol, 2005; 43:4961-4967.• “Cases were defined as patients who wereadmitted to the ICU for > 24...
Description of CasesJ Clin Microbiol, 2005; 43:4961-4967.Case Reason forAdmissionDate Date offirst cultureFirst positivesp...
Genotyping of Isolates from Patientsand OR RollboardsJ Clin Microbiol, 2005; 43:4961-4967.33
Disinfectants for non-critical itemsPractical Healthcare Epidemiology, 3rdEdition;http://www.cdc.gov/hicpac/pdf/guidelines...
Disinfectants for non-critical itemsPractical Healthcare Epidemiology, 3rdEdition;http://www.cdc.gov/hicpac/pdf/guidelines...
EXAMPLE – NOSOCOMIAL OUTBREAKOF INFECTION WITH PAN-DRUG-RESISTANT ACINETOBACTERBAUMANNII IN A TERTIARY CAREUNIVERSITY HOSP...
Case DefinitionInfect Control Hosp Epidemiol, 2009; 30:257-263.• “A case patient was defined as any inpatientwho had a pan...
Infect Control Hosp Epidemiol, 2009; 30:257-263.38
Interventions to Control Pan-Drug-Resistant Acinetobacter baumanniiInfect Control Hosp Epidemiol, 2009; 30:257-263.• Envir...
Intensified MDRO Control Measureshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Obtain consultation• Evaluat...
Intensified MDRO Control Measureshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Stop new admissions to the u...
EXAMPLE – SUCCESSFUL CONTROL OFAN OUTBREAK OF CARBAPENEMASE-PRODUCING KLEBSIELLA PNEUMONIAEIN A LONG TERM ACUTE CAREHOSPIT...
Infect Control Hosp Epidemiol, 2010; 31: 341-347.43
Bundled InterventionInfect Control Hosp Epidemiol, 2010; 31: 341-347• Daily chlorhexidine baths for all patients– 2% chlor...
Bundled InterventionInfect Control Hosp Epidemiol, 2010; 31: 341-347• Surveillance cultures on new admissions• Surveillanc...
Infect Control Hosp Epidemiol, 2010; 31: 341-347.46
EXAMPLE – MANAGEMENT OF AMULTIDRUG-RESISTANTACINETOBACTER BAUMANNIIOUTBREAK IN AN INTENSIVE CARE UNITUSING NOVEL ENVIRONME...
Case DefinitionAm J Infect Control, 2010; 38: 259• Identification of A baumannii recovered froma patient with an apparent ...
Infection Control BundleAm J Infect Control, 2010; 38: 259• Addition of a new hand hygiene product –alcohol-based hand gel...
Am J Infect Control, 2010; 38: 25950
Conclusions• MDROs can be controlled– Surveillance– Standard precautions (handwashing)– Contact precautions– Environmental...
Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute CareHospitalsInfect Control Hos...
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  • While not all studies have demonstrated these associations, and not all MDROs are associated with these bad outcomes, in general, MDROs result in many of these bad outcomes: As part of health care reform, we are called to address these issues. The spiraling cost of healthcare is in part due to spiraling rates of antibiotic resistance. It is cheaper to prevent these infections than to treat them.
  • 32 health facilities in Siouxland region (Iowa, Nebraska, South Dakota) collaborated to ‘beat back’ VRE after it first invaded the area …
  • They knew from other areas, that when VRE is identified, it rapidly progresses throughout the healthcare system of a region until it becomes endemic, and then it is very difficult to prevent or contain.
  • Collected data on specific healthcare associated infections: CLABSI CAUTI VAP SSI Post-procedure pneumonias
  • Alternate drugs sometimes used for resistant Staphylococcus aureus include: Trimethoprim-sulfamethoxazole Quinupristin – Dalfopristin Tigecycline (modified tetracycline)
  • I vancomycin resistant: options include daptomycin + aminoglycoside + another active agent, ampicillin or doxycycline with rifampin, linezolid + another active agent or high dose ampicillin + imipenem …
  • (Aminopenicillins, such as ticarcillin and piperacillin; quinolones, etc.) Colistin and Polymyxin B were discovered in 1947. After 1980, they fell into disuse because of their nephrotoxicity. They are now being used as first line drugs against suspected gram negative infections in some parts of New York City because of the high degree of resistance. Outbreaks of carbapenem-resistant, colistin resistant organisms have been reported in Detroit.
  • This study was conducted at 3 hospitals, members of Evanston Northwestern Healthcare in evanston, Ill
  • Patients followed to 30 days after discharge to determine if they had a culture documented infection with MRSA.
  • Tertiary hospital in Seville, Spain. Organism was introduced … resulted in an outbreak. This is their story of how that outbreak was controlled.
  • 75% mortality rate Only one patient was colonized. 4 patients had organ-space surgical infection 2 had meningitis 3 with respiratory infection 2 with skin or soft tissue infection Use of quinolones, glycopeptides and ICU stay were the predictors of infection in comparison with controls admitted to ICU.
  • These measures were ultimately effective in controlling transmission
  • LTAC - 70 beds attached to a short term care hospital Patients with tracheostomies who require weaning from mechanical ventilation Patients who required dialysis, intravenous antibiotics or intensive care for complex wounds
  • Drain flushing procedure: 10 gallons of water poured into each plugged sink in every location in the ICU, including in each patient room and the family waiting area. 1 gallon of bleach was then poured into the water without splashing. Plugs in all sinks were pulled simultaneously, thereby cflushing the entire horizontal drainage system. During the 10-month outbreak, 2 patients per month were infected or colonized … and 11 of the patients had an identical outbreak strain shown in black. This strain matched the strain from the sink.
  • Mdros

    1. 1. Multidrug Resistant OrganismsDanae Bixler, MD, MPH
    2. 2. Objectives• Definitions• Explain:– Which MDROs are important and why– Reservoir for MDROs– Resistance to key antibiotics– Surveillance– Control measures– Challenges of outbreak investigation2
    3. 3. Public Health Significance of Multi-Drug Resistancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Increased:– Cost– Length of stay– Admissions to ICU– Surgical procedures– Morbidity– Mortality3
    4. 4. EXAMPLE – CONTROL OF AVANCOMYCIN-RESISTANTENTEROCOCCUS IN HEALTH CAREFACILITIES IN A REGIONN Engl J Med, 2001; 344:1427-14334
    5. 5. Siouxland region of Iowa, Nebraskaand South DakotaN Engl J Med, 2001; 344:1427-1433• 4 acute care facilities• 28 long term care facilities• Population 135,000• December 1996 - April 1997 - isolates of VREincreased from 0 to 63• Meeting of health care facilities, DistrictHealth Department, state health departments,Indian Health Service5
    6. 6. Plan: Active SurveillanceN Engl J Med, 2001; 344:1427-1433Acute Care Facilities• Patients transferred fromacute care facilities outsidethe community• Patients:– hospitalized longer than 72hours;– on dialysis, with cancer,transplant or in ICU;– who have had prolongedtreatment with antimicrobialagents; or– with invasive devicesLong Term Care Facilities• Patients admitted from acutecare with unknown VRE status(pre-emptive contactprecautions)• Patients:– hospitalized longer than 72hours;– on dialysis, with cancer,transplant or in ICU;– who have had prolongedtreatment with antimicrobialagents; or– with invasive devices6
    7. 7. Plan: Infection ControlN Engl J Med, 2001; 344:1427-1433Isolation andInfectionControlPrecautionsAcute Care Facility Long Term Care FacilityRoomassignmentPrivate or cohort Private > cohort > place with non-colonized roommate IF:•Roommate has NO immunosuppressionor broken skin or renal failure AND•Both roommates able to wash hands AND•VRE patient DOES NOT HAVE urinary orfecal incontinence or draining wound7
    8. 8. Plan: Infection ControlN Engl J Med, 2001; 344:1427-1433Isolation and InfectionControl PrecautionsAcute Care Facility AND Long Term Care FacilityVRE status System of identifying the records of patients withinfection or colonizationBarrier precautions Gloves for direct patient contact; gowns forsubstantial contact with patient or body fluidsHand washing Health care workers, patients, and visitorsCare of equipment Dedicated non-critical equipment / cleaning ordisinfecting with approved disinfectantsEducation Healthcare workers, patients, visitorsCommunication VRE status indicated on transfer sheets and orally8
    9. 9. Colonization Rates, 1997 – 1999,Siouxland RegionN Engl J Med, 2001; 344:1427-1433Type ofFacilityColonization with VRENumber of Patients (%)1999 versus 19971997 1998 1999 Relative Risk (95% CI) P valueAll 40 (2.2) 26 (1.4) 9 (0.5) 0.2 (0.01 – 0.05) < 0.001Acute care 10 (6.6) 9 (5.5) 0 0 < 0.001Long termcare30 (1.7) 17 (1.0) 9 (0.5) 0.3 (0.2 – 0.7) 0.0019
    10. 10. Prevention Collaborativehttp://www.cdc.gov/hai/recoveryact/stateResources/collaborationPrimer.html• Coordinator• Multidisciplinary advisory group• Healthcare facility participation– Written commitment / Letters of support• Prevention strategies– Science-based– Feasible10
    11. 11. Prevention Collaborativehttp://www.cdc.gov/hai/recoveryact/stateResources/collaborationPrimer.html• Meetings– Agree on goals– Share learning, communication and feedback• Measurement– Select a measurement system (e.g., NHSN)– Facility commitment to participate– Regular feedback• Ongoing communication11
    12. 12. MDROs Reported to NHSN, 2006-2007Infect Control Hosp Epidemiol, 2008; 29:996-1011Organism Resistant to Number ofisolates testedResistancepercentageStaphylococcusaureusOxacillin 2736 56.2EnterococcusfaeciumVancomycin 969 80.0EnterococcusfaecalisVancomycin 1,497 6.9PseudomonasaeruginosaFluoroquinolones 2,185 30.7Piperacillin orpiperacillin/tazobactam1545 17.5Amikacin 1,444 6.0Imipenem or miropenem 1,558 25.3Cefepime 1,604 11.212
    13. 13. MDROs Reported to NHSN, 2006-2007Infect Control Hosp Epidemiol, 2008; 29:996-1011Organism Resistant to Number ofisolates testedResistancepercentageKlebsiellapneumoniaeCeftriaxone or ceftazidime 329 - 579 21.2 – 27.1Imipenem, meropemen orertapenem302 - 452 3.6 – 10.8Klebsiella oxytoca Ceftriaxone or ceftazidime 232 16.8Imipenem, meropemen orertapenem181 2.8AcinetobacterbaumanniiImipenem or meropemen 82 - 427 25.6 – 36.8Escherichia coli Ceftriaxone or ceftazidime 173 – 1,577 5.5 – 11.0Imipenem, meropemen orertapenem163 - 871 0.9 – 4.0Fluoroquinolones 255 – 1,920 22.7 – 30.813
    14. 14. Reservoirs for MDROsOrganism Reservoir Colonizes In hospital environmentStaphylococcusaureusNares, skin Nares, skin Stethoscopes, pagers, bed spaces,linens, wheelchairs, doorknobs,workstations, telephones …EnterococcusspeciesIntestines Intestines Bed rails, linens, doorknobs,bedpans, urinals, blood pressurecuffs, stethoscopes, monitoringequipmentPseudomonasaeruginosaSoil, water,plantsAxilla, ear,perineum,respiratory tractDrains, toilets, showers, water inpatient equipmentAcinetobacterspeciesSoil, water,foodPharynx,especiallytracheostomyTap water, peritoneal dialysatebath, urinals, washcloths, soapdispensersEnterobacteriaceae(Klebsiella,Enterobacter, E.Coli)Intestines Oropharynx,genitourinarytractSinks, ultrasonography gel, bathsoap, water baths14
    15. 15. Resistance 101Staphylococcus aureusAntibiotic ResistancemechanismLabel Alternate antibioticsPenicillin β – lactamase(inducible plasmid)Nafcillin, oxacillin,methicillinMethicillin(penicillinase-stableβ-lactam antibiotic)Staphylococcalchromosomalcasette (SCC) mec•6 types•Associated withresistance to otherantibiotics•MRSA •VancomycinGlycopeptides •Chromosomalmutation•VRSA•VISA•?15
    16. 16. Resistance 101EnterococcusAntibiotic ResistancemechanismLabel AlternateantibioticsAmpicillin Decreased bindingof antibiotic(chromosomal)Ampicillin resistant Ampicillin andaminoglycosideAminoglycosides Aminoglycoside-modifying enzyme(chromosomal)High-level(aminoglycoside)resistant (HLR)VancomycinVancomycin Reduced binding ofdrug to cell wall(plasmid)VRE •?16
    17. 17. Resistance 101Gram Negative BacilliAntibiotic ResistancemechanismLabel AlternateantibioticsPenicillins, 1st, 2ndand 3rdgenerationcephalosporins andaztreonamExtended-spectrumβ – lactamasesChromosomal orplasmid•Also frequentlyresistant to:fluoroquinolones,co-trimoxazole,trimethoprimESBL-producing - CarbapenemsCarbapenems Carbapenemase•Transposon(mobile geneticmaterial)CRE (Carbapenemresistantenterobacteriaceae)•? / Colistin andPolymyxin B17
    18. 18. Types of Infections Caused by MDROsGram (+) CocciMandell, 7thEditionBacteria Types of infectionsStaphylococcus aureus •Surgical site infections (SSI)•Central line-associated bloodstreaminfections (CLABSI)•Ventilator-associated pneumonias(VAP)•Bacteremia•Osetomyelitis, septic arthritis•Other organs …18
    19. 19. Types of Infections Caused by MDROsGram (+) Cocci (2)Mandell, 7thEditionBacteria Types of infectionsEnterococcus species •Bacteremia•Catheter-associated urinary tractinfections (CAUTI)•Intra-abdominal and pelvic infections•Neonatal infections•Skin and soft tissue19
    20. 20. Types of Infections Caused by MDROsGram (-) BacilliMandell, 7thEditionBacteria Types of infectionsPseudomonas aeruginosa •Bacteremia•Acute pneumonia, chronic respiratory infections•Bone and joint•Ear, eye•UTI•Skin and soft tissue (e.g., burns)Acinetobacter species •Pneumonia•Bacteremia•Cellulitis after surgery or traumaEnterobacteriaceaeKlebsiella speciesEnterobacter spE.coli•UTI•Neonatal bacteremia•Sepsis and meningitis•Pneumonia•Wound and burn infections•CLABSIs20
    21. 21. Surveillancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Routine clinical cultures (antibiograms)– Detect emergence of new MDROs– Facility- or unit- specific summary antimicrobialsusceptibility reports• Monitor for changes• MDRO incidence (new isolates per 1000patient days or per month)– Monitor trends / evaluate impact of prevention– Does not distinguish colonization from infection21
    22. 22. Surveillancehttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• MDRO infection rates– Requires clinical data– Helpful in defining clinical impact• Molecular typing– Confirm clonal transmission– Evaluate interventions in facility22
    23. 23. Active Surveillance Cultureshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Prospective identification of colonized persons• Coupled with intervention can reducetransmission• Resource intensive• Methods– MRSA: nares > perirectal and wound– VRE: stool, rectal or perirectal– MDR-GNB: peri-rectal or rectal alone or incombination with oropharyngeal, endotracheal,inguinal, or wound23
    24. 24. EXAMPLE – UNIVERSAL SURVEILLANCEFOR MRSA IN 3 AFFILIATED HOSPITALSAnn Intern Med, 2008; 148:409-418.24
    25. 25. Infection Control StrategiesEvanston Northwestern HealthcareAnn Intern Med, 2008; 148:409-418• 3 hospitals– 40,000 annual admissions– 450 staff physicians• Contact isolation for MRSA-colonized persons– Private room or cohort– Gowns and gloves for all room entries– Dedicated equipment, e.g., stethoscopes25
    26. 26. Study DesignAnn Intern Med, 2008; 148:409-418Timeframe Period 1 (Aug 1,2003 – July 31,2004)Period 2 (Aug 1,2004 – July 31,2005)Period 3 (Aug 1,2005 – April 2007)Strategy No activesurveillanceASC at ICUadmissionASC at anyadmissionAdmissions tested(%)0 (0%) 3334 (75.9%) 62,035 (84.4%)Positive test results 0 277 (8.3%) 3926 (84.4%)Contact precautionsfor MRSAyes yes yesRoutinedecolonizationno no Mupirocin,chlorhexidineMRSA per 10,000patient-days(95% CI)8.9(7.6 – 10.4)7.4(6.1 – 9.0)3.9(3.2 – 4.7)26
    27. 27. Ann Intern Med, 2008; 148:409-41827
    28. 28. Infection Control Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Standard precautions– Masks for:• Splash-generating procedures• Patients with open tracheostomies• Circumstances when there is evidence of transmission from heavily colonizedsources (e.g., burns)• Contact precautions– All patients with infections or previously identified as colonized– Patients with ability to perform hand hygiene and without drainingwounds, diarrhea, uncontrolled secretions: establish ranges ofpermitted ambulation, socialization and use of common areas basedon risk …• Cohorting, in order of preference:– Single patient room– Cohort with patient with same MDRO– Cohort with low-risk patient28
    29. 29. Infection Control Precautionshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Environmental measures– Increased cleaning of:• Items in close proximity to patient, e.g., bed rails, over-bed tables• Frequently touched surfaces– Monitoring• Decolonization29
    30. 30. EXAMPLE – OUTBREAK OF INFECTIONWITH A MULTIRESISTANT KLEBSIELLAPNEUMONIAE STRAIN ASSOCIATEDWITH CONTAMINATED ROLL BOARDSIN OPERATING ROOMSJ Clin Microbiol, 2005; 43:4961-4967.30
    31. 31. Case definitionJ Clin Microbiol, 2005; 43:4961-4967.• “Cases were defined as patients who wereadmitted to the ICU for > 24 h in November2000 and who were positive for MRKP* byculture of specimens taken between 1November 2000 and 31 December 2000.• Samples for culture were taken from specificinfection sites or for surveillance, and samplesfrom both colonized and infected patientwere included.”*resistant to trimethoprim-sulfamethoxazole and aminoglycosides; ESBLpositive31
    32. 32. Description of CasesJ Clin Microbiol, 2005; 43:4961-4967.Case Reason forAdmissionDate Date offirst cultureFirst positivespecimenDaysbetweensurgery andcollection1 Laparotomy 10/26 11/2 Abdominal wounds 42 Subdural empyema 11/4 11/6 Sputum 23 Trauma 11/8 11/11 Blood 24 Pancreatitis 10/30 11/18 Discharge from ear 15 Esophagealresection10/18 11/18 Discharge fromthorax drain56 Laparotomy 11/7 11/23 Sputum 157 Subarachnoidhemorrhage11/24 12/19 CSF none32
    33. 33. Genotyping of Isolates from Patientsand OR RollboardsJ Clin Microbiol, 2005; 43:4961-4967.33
    34. 34. Disinfectants for non-critical itemsPractical Healthcare Epidemiology, 3rdEdition;http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf• Chlorine-based products– Sporicidal– Corrosive– Respiratory irritant– Inactivation by organic matter• Phenolics– Bactericidal, fungicidal, virucidal, tuberculocidal– Tissue irritant– Hyperbilirubinemia in neonatal nursery34
    35. 35. Disinfectants for non-critical itemsPractical Healthcare Epidemiology, 3rdEdition;http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf• H2O2– Bactericidal, fungicidal, virucidal, sporicidal– Chemical irritant• Quaternary ammonium compounds– Bactericidal, fungicidal, virucidal against lipophilic (enveloped)viruses– Not sporicidal, tuberculocidal or active against hydrophilicviruses.– Inactivated by water hardness and cotton• 70-90% alcohol– Virucidal, tuberculocidal– Lack sporicidal action and cannot penetrateprotein-rich materials– Damage some surfaces after repeated use35
    36. 36. EXAMPLE – NOSOCOMIAL OUTBREAKOF INFECTION WITH PAN-DRUG-RESISTANT ACINETOBACTERBAUMANNII IN A TERTIARY CAREUNIVERSITY HOSPITALInfect Control Hosp Epidemiol, 2009; 30:257-263.36
    37. 37. Case DefinitionInfect Control Hosp Epidemiol, 2009; 30:257-263.• “A case patient was defined as any inpatientwho had a pan-drug-resistant A baumanniiisolate recovered from a clinical orsurveillance sample obtained at least 48 hoursafter ICU admission {from April 9, 2002 toMarch 9, 2003}.”37
    38. 38. Infect Control Hosp Epidemiol, 2009; 30:257-263.38
    39. 39. Interventions to Control Pan-Drug-Resistant Acinetobacter baumanniiInfect Control Hosp Epidemiol, 2009; 30:257-263.• Environmental decontamination• Environmental survey• Revision of cleaning protocols• Active surveillance for PDRAB– Rectal and pharyngeal swabs of roommates• Educational programs for the staff• Display of posters illustrating isolation measuresand antimicrobial use recommendations39
    40. 40. Intensified MDRO Control Measureshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Obtain consultation• Evaluate staffing and resources• Educate• Judicious antimicrobial use• Active surveillance and pre-emptive contactisolation• Contact precautions for all colonized orinfected patients40
    41. 41. Intensified MDRO Control Measureshttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf• Stop new admissions to the unit or facility iftransmission continues• Dedicated use of non-critical equipment• Training for environmental staff• Monitor cleaning• Vacate units for intensive cleaning when previousefforts fail• Decolonization for MRSA (only) with expertconsultation41
    42. 42. EXAMPLE – SUCCESSFUL CONTROL OFAN OUTBREAK OF CARBAPENEMASE-PRODUCING KLEBSIELLA PNEUMONIAEIN A LONG TERM ACUTE CAREHOSPITALInfect Control Hosp Epidemiol, 2010; 31: 341-347.42
    43. 43. Infect Control Hosp Epidemiol, 2010; 31: 341-347.43
    44. 44. Bundled InterventionInfect Control Hosp Epidemiol, 2010; 31: 341-347• Daily chlorhexidine baths for all patients– 2% chlorhexidine from the jawline downward• Observational study of terminal cleaning– Bedrails, IV pumps, poles, respiratory tubing, etc. notcleaned at all• Environmental cleaning– Cleaning personnel - clean all surfaces– Respiratory therapy - nightly cleaning of allmechanical ventilator surfaces and O2 valves– Nursing – disinfect all shared objects– All bedside curtains replaced44
    45. 45. Bundled InterventionInfect Control Hosp Epidemiol, 2010; 31: 341-347• Surveillance cultures on new admissions• Surveillance rectal swabs on all patients• Isolation and contact precautions– High risk patients placed in pre-emptive contactisolation (CI) on admission until documented (-)– (+) patients placed in CI• Personnel education• Environmental cultures to monitor cleaning45
    46. 46. Infect Control Hosp Epidemiol, 2010; 31: 341-347.46
    47. 47. EXAMPLE – MANAGEMENT OF AMULTIDRUG-RESISTANTACINETOBACTER BAUMANNIIOUTBREAK IN AN INTENSIVE CARE UNITUSING NOVEL ENVIRONMENTALDISINFECTION: A 38 MONTH REPORTAm J Infect Control, 2010; 38: 259.47
    48. 48. Case DefinitionAm J Infect Control, 2010; 38: 259• Identification of A baumannii recovered froma patient with an apparent clinical infectiondue to this pathogen after more than 2 days inthe ICU.48
    49. 49. Infection Control BundleAm J Infect Control, 2010; 38: 259• Addition of a new hand hygiene product –alcohol-based hand gel in each patient room• Hand hygiene training• Observations of environmental cleaning• Contact isolation of all MDR A baumanniipatients• Environmental culturing– A baumannii isolated from drain49
    50. 50. Am J Infect Control, 2010; 38: 25950
    51. 51. Conclusions• MDROs can be controlled– Surveillance– Standard precautions (handwashing)– Contact precautions– Environmental cleaning– Monitoring of above– Interfacility collaboration and communication51
    52. 52. Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute CareHospitalsInfect Control Hosp Epidemiol, 2008; 29(Suppl 1): S62• MRSA risk assessment• MRSA monitoring program• Hand hygiene guidelines• Contact precautions for MRSA-infected or colonizedpatients• Cleaning and disinfection of equipment and theenivronment• Educate• Laboratory alert system• Provide MRSA data and outcome measures to keystakeholders• Educate patients and families52

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