Mdro infection controlnursing final version 11.17.09 1


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Mdro infection controlnursing final version 11.17.09 1

  1. 1. MDRO (Multiple drug-resistant organisms)<br />How they relate to patients in the healthcare setting<br />UT Southwestern University Hospitals: Infection Control Department<br />
  2. 2. Multi-drug resistant organisms (MDRO’s) have increased in prevalence in US hospitals over the last three decades<br />These organisms have important implications for patient safety<br />Options for treating patients with these infections are often extremely limited<br />MDRO infections are associated with increased lengths of stay, costs, and mortality<br />Background<br />
  3. 3. Methicillin Resistant Staphylococcus aureus (MRSA) was first isolated in the United States in 1968. <br />In the early 1990s, MRSA accounted for 20%-25% of Staphylococcus aureus isolates from hospitalized patients. <br />By 2003, MRSA accounted for >50% of S. aureus isolates from patients in ICUs.<br />A similar rise in prevalence has occurred with Vancomycin Resistant Enterococcus (VRE) . From 1990 to 1997, the prevalence of VRE in Enterococcus isolates from hospitalized patients increased from <1% to approximately 15% . <br />By 2003 VRE accounted for 28.5 % of Enterococcus isolates in ICUs.<br />History of MDRO’s<br />
  4. 4. Methicillin-Resistant Staphylococcus aureus (MRSA)<br />Vancomycin-Resistant Enterococcus species <br /> (VRE)<br />Multidrug-Resistant (MDR) Acinetobacter species.<br />Multidrug-Resistant (MDR) Klebsiella species, Enterobacter species, and Escherichia coli.<br />Resistant Organisms include:<br />
  5. 5. To be defined as an MDRO the organism must meet these criteria:<br />MRSA: S. aureus tests resistant to Oxacillin<br />VRE: Enterococcus species tests resistant to Vancomycin.<br />MDRO-Acinetobacter species: Resistant to all agents tested within at least 3 antimicrobial classes, including B-lactams, carbapenems, aminoglycosides and fluoroquinolones <br />Specific definitions<br />
  6. 6. Resistant Bacteria<br />Mutations<br />XX<br />Resistance Gene Transfer<br />New Resistant Bacteria<br />Emergence of Antimicrobial Resistance<br />Susceptible Bacteria<br />Bacteria have evolved to evade antimicrobial drugs through chromosomal mutations & acquisition of resistance genes via conjugation, transposition, or transformation<br />
  7. 7. Resistant StrainsRare<br />Antimicrobial <br />Exposure<br />x<br />Resistant Strains <br />Dominant<br />x<br />x<br />x<br />x<br />x<br />x<br />x<br />x<br />x<br />x<br />x<br />Selection for antimicrobial-resistant Strains<br />Once resistant strains of bacteria are present in a population, exposure to antimicrobial drugs favors their survival.<br />
  8. 8. Methicillin<br />Methicillin-resistant<br />S. aureus (MRSA)<br />[1970s]<br />Vancomycin<br />[1997]<br />[1990s]<br />[ ???? ]<br />Vancomycin-resistant<br />Vancomycin<br />Vancomycin-<br />resistant<br />S. aureus<br />enterococci (VRE)<br />intermediate-<br />resistant<br />S. aureus<br />(VISA)<br />Penicillin<br />Penicillin-resistant<br />S.aureus<br />[1950s]<br />S. aureus<br />Introduction of every new class of antimicrobial drug is followed by emergence of resistance<br />
  9. 9. B-lactams: includes ampicillin/sulbactam, piperacillin/tazobactam, cefepime, ceftazidime<br />Carbapenems: includes imipenam, meropenem and doripenam<br />Aminoglycosides: includes amikacin, gentamycin, tobramycin<br />Fluoroquinolones: includes ciprofloxacin, levofloxacin<br />Drug classes:<br />
  10. 10. Staphylococcus aureus<br />commonly found on skin, in eyes, upper respiratory track, mouth, and GU system<br />developed resistance to many Antibiotics including Methicillin (oxacillin) to create the particular strain, MRSA<br />MRSA <br />Is found anywhere Staphylococcus aureus is commonly found<br />may colonize the patient or cause active infections<br />is a public health concern because there are few drugs left to treat serious MRSA infections. Vancomycin is the current drug of choice for serious infections. Other antimicrobial agents would include: Daptomycin and Linezolid.<br />A high percentage of wound infections are caused by MRSA.<br />Reservoirs for MRSA in the hospital include infected or colonized patients with HCW being the link for nosocomial spread of the infection. The main mode of transmission is via hands of HCW.<br />Other reservoirs include contaminated equipment and other items in the environment<br />Methicillin-Resistant Staphylococcus aureus (MRSA)Fact Sheet<br />
  11. 11. The emergence of new epidemic strains of MRSA in the community, (CA-MRSA) among patients without established MRSA risk factors, may present new challenges to MRSA control in healthcare settings.<br />Historically, genetic analyses of MRSA isolated from patients in hospitals worldwide revealed a relatively small number of MRSA strains have the unique qualities to facilitate transmission from patient to patient.<br />To date, most MRSA strains isolated from patients with CA-MRSA infections have been microbiologically distinct from those endemic in healthcare settings, suggesting some of these strains may have arisen de novo in the community via the acquisition of the mecA gene from Methicillin Susceptible Staph aureus.<br />CA-MRSA infection commonly presents as relatively minor skin and soft tissue infections, but severe invasive disease and mortalities have been described in children and adults. <br />Community-associated MRSA<br />
  12. 12. When a patient is identified as having an infection or colonization with an MDRO:<br />Place the patient in Contact Precautions <br />Enter the isolation information into EPIC<br />Staff will be alerted of isolation status upon subsequent admissions into the hospital<br />Monitoring of MDRO’s<br />
  13. 13. Infection control monitors MDRO incidence and transmission and provides data monthly and quarterly to the units<br />Monitoring of MDRO’s<br />
  14. 14. Removing Patients From Isolation<br />Follow-up screenings MUST be negative: <br />Original site of infection<br /> +<br />Nasal if previously MRSA positive<br /> or<br />Rectal if previously VRE positive<br />Once the C. Diff positive patient is discharged, the isolation is removed automatically<br />Notify Infection Control to Remove Isolation Status from EPIC<br />
  15. 15. Once MDROs are introduced into a healthcare setting, transmission and persistence of the resistant strain is determined by the:<br />availability of vulnerable patients<br />selective pressure exerted by antimicrobial use.<br />the number of patients already colonized with an MDRO<br />the impact of implementation and adherence to prevention efforts<br />Patients vulnerable to colonization and infection include:<br />those with severe disease<br />those with compromised host defenses from underlying medical conditions<br />recent surgery<br />indwelling medical devices (e.g., urinary catheters or endotracheal tubes)<br />Hospitalized patients have more risk factors than non-hospitalized patients, and have the highest infection rates.<br />
  16. 16. Hands are the culprits<br />There is ample epidemiologic evidence to suggest MDROs are carried from one person to another via the hands of HCW. <br />Hands are easily contaminated during the process of care-giving or from contact with environmental surfaces in close proximity to the patient. <br />Without adherence to published recommendations for hand hygiene and glove use HCW are more likely to transmit MDROs to patients. <br />Strategies to increase and monitor adherence are important components of MDRO control programs.<br />
  17. 17. Standard Precautions are a group of infection prevention practices which apply to all patients, regardless of suspected or confirmed infection status. They are in effect for all patients, all the time.<br />These include the use of: *<br />Hand hygiene<br />Gloves<br />Gown<br />Mask<br />Eye protection, or face shield<br />*depending on the anticipated exposure; and safe injection practices.<br />Equipment or items in the patient environment likely to have been contaminated with body fluids must be handled in a manner to prevent transmission of infectious agents.<br />
  18. 18. While good hand hygiene remains the most important method to prevent the transmission of any organism on the hands of HCW, the addition of Contact Precautions can break the chain of infection by preventing the organisms from being carried from one room to another on inanimate objects (foamites).<br />Contact Precautions<br />
  19. 19. Touching the PATIENT isn’t the only way to become contaminated with an MDRO!<br />
  20. 20. Contact Isolation Precautions<br />Place green Contact Isolation sign on the room door<br />Any PERSON entering the room wears gloves and gown, no matter the reason for entering the room or for how long. This includes all staff and visitors.<br />
  21. 21. Contact Isolation Precautions<br />Remove Personal Protective Equipment and perform hand hygiene BEFORE leaving the room.<br />Equipment from a Contact Precautions room should be disinfected before being used for the care of another patient .<br />
  22. 22. Contact Isolation Precautions Sign<br />
  23. 23. Stop Sign for Clostridium difficile<br />Contact Precautions<br />+<br />Use ONLY soap & water to wash hands<br />
  24. 24. Droplet Isolation Precautions Sign<br />
  25. 25. Airborne Isolation Precautions Sign<br />
  26. 26. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults<br />
  27. 27. Prevent Infection:<br />Get the catheters out<br />Fact:Catheters and other invasive devices are the #1 exogenous cause of hospital-onset infections.<br />Actions:<br /><ul><li>Use catheters only when essential
  28. 28. Use the correct catheter
  29. 29. Use proper insertion & catheter-care protocols
  30. 30. Remove catheters when not essential </li></li></ul><li>Antimicrobial-Resistant Pathogen<br />Prevent<br />Infection<br />PreventTransmission<br />Infection<br />Antimicrobial Resistance<br />Effective<br />Diagnosis<br />& Treatment<br />Optimize Use<br />Antimicrobial Use<br />Susceptible Pathogen<br />Antimicrobial Resistance:Key Prevention Strategies<br />Pathogen<br />
  31. 31. The Infection Control Team<br />Doramarie Arocha<br />David Townson<br />Gwen Way<br />
  32. 32. Use Antimicrobials WiselyTreat infection, not colonization<br />Fact:A major cause of antimicrobial overuse is treatment of colonization. <br />Actions:<br /><ul><li>Treat pneumonia, not the tracheal aspirate
  33. 33. Treat bacteremia, not the catheter tip or hub
  34. 34. Treat urinary tract infection, not the indwelling catheter </li></li></ul><li>Biofilm on Intravenous Catheter Connecter 24 hours after Insertion<br />Scanning Electron Micrograph<br />
  35. 35. Know when to say “no” to vanco<br />Fact: Vancomycin overuse promotes emergence, selection, and spread of resistant pathogens.<br />Actions:<br />Treat infection, not contaminants or colonization <br />Fever in a patient with an intravenous catheter is not a routine indication for vancomycin<br />
  36. 36. Use Antimicrobials Wisely When to stop antimicrobial treatment<br />Fact:Failure to stop unnecessary antimicrobial treatment contributes to overuse and resistance.<br />Actions:<br /><ul><li>When infection is cured
  37. 37. When cultures are negative and infection is unlikely
  38. 38. When infection is not diagnosed</li></li></ul><li>Prevent Transmission<br />Fact:Patient-to-patient spread of pathogens can be prevented.Actions:<br /><ul><li>Use standard infection control precautions
  39. 39. Contain infectious body fluids</li></ul> (use approved airborne/droplet/contact isolation precautions)<br /><ul><li>When in doubt, consult infection control experts</li></li></ul><li>Prevent Transmission: <br />Contain your contagion<br />Fact:Healthcare personnel spread antimicrobial-resistant pathogens from patient-to-patient.<br />
  40. 40. Prevent Transmission: Contain your contagion<br />Patients from Long Term Acute Care Facilities (LTAC) have a higher incidence of being colonized with an MDRO<br />Isolate immediately upon arrival, no questions asked!<br />Follow MDRO Reduction Protocol<br />Notify Infection Control<br />
  41. 41. <ul><li>Life Care
  42. 42. Dallas
  43. 43. Fort Worth
  44. 44. Plano
  45. 45. Vibra Specialty Hospital
  46. 46. Texas Specialty Hospital
  47. 47. Kindred Specialty Hospital
  48. 48. Multiple Locations in Dallas and Fort Worth
  49. 49. Arlington
  50. 50. Mansfield
  51. 51. Gulf States LTAC
  52. 52. Select Specialty
  53. 53. DeSoto
  54. 54. Carrolton
  55. 55. Mesquite Specialty Hospital
  56. 56. Regency Hospital
  57. 57. Carrolton
  58. 58. Fort Worth
  59. 59. Plano Specialty Hospital
  60. 60. Baylor Specialty Hospital</li></ul>Multi-Drug Resistant Organism Reduction (MDRO) Protocol: Known LTACs<br />
  61. 61. Multi-Drug Resistant Organism (MDRO) Reduction Screening Protocol<br />
  62. 62. How to Obtain a Nasal Swab/Culture for MRSA Screen <br />Steps:<br />Wash hands, apply clean gloves<br />Peel open the BBL CultureSwab sterile pouch at the point indicated by the diagram on the outside of the package.<br />Twist to remove the cap from the transport tube<br />Remove the swab<br />Insert the swab approximated 2 cm (approximately ¾ inch) into the naris.<br />Rotate the swab against the anterior nasal mucosa for 3 seconds<br />Using the same swab, repeat for the other naris.<br />**If using swab with 2 heads, can use 1 swab for each naris.<br />Equipment:<br /><ul><li>Clean disposable gloves
  63. 63. BBL CultureSwab</li></li></ul><li>How to Obtain a Nasal Swab/Culture for MRSA Screen--Continued<br /><ul><li>Place in biohazard bag
  64. 64. Transport the labeled specimen to the lab WITHIN 1 HOUR.
  65. 65. Label the swab with the patient’s preprinted label in the presence of the patient, in the patient’s room
  66. 66. Remove and discard gloves
  67. 67. Place in biohazard bag
  68. 68. Transport the labeled specimen to the lab WITHIN 1 HOUR.</li></ul>Push the end of the swab firmly to ensure that the swab is inserted into the end of the transport tube. Ensure that the swab tip is in contact with the moistened pledget.<br />Secure the transport tube cap.<br />Label the swab with the patient’s preprinted label in the presence of the patient, in the patient’s room<br />Remove and discard gloves<br />
  69. 69. Prevent TransmissionBreak the chain of contagion<br />Fact:Healthcare personnel spread antimicrobial-resistant pathogens from patient to patient.<br />Actions:<br /><ul><li>Stay home when you are sick
  70. 70. Contain your contagion
  71. 71. Keep your hands clean
  72. 72. Set an example!</li></li></ul><li>