Monitoring mdro in healthcare

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Monitoring mdro in healthcare

  1. 1. Multi Drug ResistantMulti Drug Resistant Organisms (MDROs) in HealthOrganisms (MDROs) in Health Care setting :Care setting : use of standardized metrics touse of standardized metrics to monitor local prevention effortsmonitor local prevention efforts Dr. Ashok Rattan, Chief Executive, Fortis Clinical Research Ltd., Adviser, Religare SRL Diagnostics labs in Fortis / Escorts Hospitals, Delhi & NCR
  2. 2. 100 80 60 40 20 0 19801975 1985 1990 1995 2000 1997 VISAVISA VREVRE PRSPPRSP MRSAMRSA MRSEMRSE Percentage of Pathogens Resistant to Antibiotics Increasing Incidence of Resistance in the US MRSE, MRSA, VRE, PRSP, GISA 1980-2006 VRSAVRSA 2006
  3. 3. Crisis of Pan Resistant Bacteria • Pre existing or Acquisition of new resistance by bacteria Mutation Spread within clone Vertical Horizontal • Expansion of clone & Dissemination of resistant bacteria Biological PhenomenonBiological Phenomenon Partly Mechanical PhenomenonPartly Mechanical Phenomenon
  4. 4. Antibiotic Stewardship Programme • Effective antimicrobial stewardship – Audit & feedback – Guidelines & algorithms – Antibiotic order form – Combination – De escalation – Dose optimization – Parentral  oral – Cycling • Comprehensive Infection control – Managing data and information – Policies & procedures – Regulatory requirements – Employee health – Prevent transmission, investigate outbreaks – Education & training – Mobilize resources: human & financial
  5. 5. Monitoring MDROs is important • To – Detect newly emerging antimicrobial profile – Identify vulnerable patient population – Assess need for & effectiveness of, intervention • Why – Incidence has increased in the past decades – Options for treatment are limited – Has important implications for patient safety – Associated with prolonged stay, costs and mortality
  6. 6. Which MDROs should we monitor ? Choice need to be facility based • May include: – MRSA & VRSA – VRE – MDR GNB • Pseudomonas aeruginosa • Acinetobacter baumannii • Klebsiella pneumoniae • Escherichia coli • Before staring make sure clear cut definitions are in place & understood by all participating in surveillance
  7. 7. MDROs Metrics 5 categories of outcome measures 1. Tracking patients 2. Monitoring susceptibility patterns 3. Estimating infection burden 4. Estimating Exposure burden 5. Quantifying healthcare acquisition Preventive Process Measures • Monitor adherence to Hand Hygiene • Monitor adherence to Gown & Glove use • Monitor adherence to Active Surveillance Testing
  8. 8. 1. Tracking patient • A. Line listing: – Not a rate, so no denominator, – No defined period, continuously updated – Essential elements of line listing: » Pt identification, » Hospital location » Date of admission » Date and time of sample collection » Source of sample » Date of first positive – Useful to flag patients for » identification and » contract isolation
  9. 9. A. Line Listing • Simple • Could be the only essential metrics for rare MDROs • For common MDROs like MRSA it provides – Identification of patient – History of infection or colonization • Can trigger & follow outbreak investigation for new or rapidly emerging MDROs • Initial part of any risk assessment; identifies pts with a prior history of colonization or infection. This might be the only metrics necessary for rare MDROs (eg VRSA)
  10. 10. 1. Tracking patient A. Line Listing • Type of microbiology data required: – Clinical culture data (& AST data if available) • Numerator – Pt with newly recovered MDRO isolate (regardless of specimen source) by HCF • Denominator – None • Surveillance interval – Continuous • Location of use – Whole HCF
  11. 11. 2. Monitoring susceptibility pattern • A. Antibiogram: • To provide guidance for antimicrobial prescription • Monitor progress is assessing proportion of MDRO resistant to certain antibiotics of interest • CLSI Recommendations of Antibiogram: 1.Methods of summarizing susceptibility data 2.Report results in “percent susceptible” 3.Organisms morphological grouping 4.Duplicate isolate notification 5.Description of exact collection period. 6.Number of isolates for each organism. 7.Reporting only organisms with greater than 30 isolates. 8.Use of Generic names of antimicrobials. 9.Utilization of CLSI approved antimicrobial abbreviations. 10.Utilization of “dash” to describe susceptibility data not reported 11.Annual reporting of results
  12. 12. 2. Monitoring Susceptibility Pattern A. Antibiogram • Type of microbiology data required: – Clinical culture data • Numerator – Number of first susceptible clinical isolates (regardless of specimen source) per pt for each unit or HCF • Denominator – Total number of isolates (both S & R) per pt. for each unit or HCF • Surveillance interval – Atleast annually • Location of use – Whole HCF (consider use for specific units or populations)
  13. 13. 3. Estimation of Infection Burden A. Metrics: Incidence or Incidence density rate of hospital onset bacteremia Basic for all MDROs, especially for emergence of new resistance
  14. 14. 3. Estimation of Infection Burden A. Incidence density rate of hospital onset bacteremia • Type of microbiology data required – Blood culture data only • Numerator – Number of MDRO isolates recovered from blood samples for each unit or HCF > 3 calendar days after admission to unit or HCF • Denominator – 100 pt admissions (incidence); 1000 pt days ( inc. density) • Surveillance interval – Monthly • Location of use – Specific units (consider use for whole HCF)
  15. 15. B. Metrics: Nosocomial organism specific infection incidence or incidence density Useful for assessing burden of a specific organism regardless of extrinsic risk factors (eg catheter or ventilator use) 3. Estimation of Infection Burden
  16. 16. 3. Estimation of Infection Burden B. Nosocomial organism specific infection incidence • Type of microbiology data required – Clinical culture data only • Numerator – Number of hospital onset MDRO infections meeting standard infection criteria • Denominator – 100 pt admissions (incidence); 1000 pt days ( inc. density) • Surveillance interval – Monthly • Location of use – Specific units (consider use for whole HCF)
  17. 17. C. Metrics: Organism specific, devise associated associated incidence density : Useful for assessing the burden of specific device associated infections. 3. Estimation of Infection Burden
  18. 18. 3. Estimation of Infection Burden c. Organism specific, devise associated incidence density • Type of microbiology data required – Clinical culture data only • Numerator – Number of devices associated MDRO infections • Denominator – 1000 device days • Surveillance interval – Monthly • Location of use – Specific units (consider use for whole HCF).
  19. 19. D. Metrics: Organism & procedure specific incidence density Useful for assessing the burden of specific procedure associated infections or in specific populations 3. Estimation of Infection Burden
  20. 20. 3. Estimation of Infection Burden D. Organism & procedure specific incidence density • Type of microbiology data required – Clinical culture data only • Numerator – Number of procedures associated MDRO infections • Denominator – 100 procedures • Surveillance interval – Monthly (or quarterly) • Location of use – Not applicable
  21. 21. 4. Estimating Exposure Burden A. Metrics: Overall prevalence or prevalence density rate based on clinical culture data Reasonable initial risk assessment, underestimates hidden reservoirs for MRSA, VRE & MDR GNB
  22. 22. 4. Estimating Exposure Burden A. Overall prevalence or prevalence density rate based on clinical culture data • Type of microbiology data required – Clinical culture data only • Numerator – Number of first MDRO isolated per pt per unit regardless of time pt spent in the unit and number of pts with history of colonization or infection • Denominator – 100 pt admission (P); 1000 pt days (prevalence density) • Surveillance interval – Monthly (or quarterly) • Location of use – Specific unit (consider use for whole HCF)
  23. 23. 4. Estimating Exposure Burden B. Metrics Overall prevalence or prevalence density rate based on clinical culture and AST data Very useful for robust assessment of intervention if conducting AST
  24. 24. 4. Estimating Exposure Burden B. Overall prevalence or prevalence density rate based on clinical culture and AST data • Type of microbiology data required – Clinical culture and AST data • Numerator – Number of first MDRO isolated per pt per unit regardless of time pt spent in the unit and number of pts with history of colonization or infection • Denominator – 100 pt admission (P); 1000 pt days (prevalence density) • Surveillance interval – Monthly • Location of use – Specific unit (consider use for whole HCF)
  25. 25. 4. Estimating Exposure Burden C. Metrics Admission prevalence rate based on clinical culture data with or without AST Useful adjunct metrics if there is concern about importation from community or other HCF
  26. 26. 4. Estimating Exposure Burden C. Admission prevalence rate based on clinical culture data with or without AST • Type of microbiology data required – Clinical culture data with or without AST • Numerator – Number of first MDRO isolated per pt per unit < 3 calendar days after admission to the unit and number of pts with history of colonization or infection • Denominator – 100 pt admissions • Surveillance interval – Monthly • Location of use – Specific unit (consider use for whole HCF)
  27. 27. 4. Estimating Exposure Burden D. Metrics Point prevalence rate based on point prevalence surveys * Useful adjunct metric for HCF not conducting routine AST. * Help provide as estimate of the degree to which clinical culture data underestimates the full reservoir. * Could guide HCF when to start AST in select population or units. * Very useful in defining high risk areas or population of an HCF.
  28. 28. 4. Estimating Exposure Burden D. Point prevalence rate based on point prevalence surveys • Type of microbiology data required – Clinical culture and AST data • Numerator – Number of MDRO isolated per pt per unit or HCF • Denominator – 100 pt admissions • Surveillance interval – Point in time • Location of use – Specific unit (consider use for whole HCF)
  29. 29. 5. Quantifying Healthcare Acquisition A. Metrics: Incidence or incidence density rate of hospital onset MDRO Useful for VRE & MDR GNB during outbreak, but underestimates the hidden reservoir
  30. 30. 5. Quantifying Healthcare Acquisition A. Incidence or incidence density rate of hospital onset MDRO • Type of microbiology data required – Clinical culture data only • Numerator – Number of first MDRO isolated per pt per unit > 3 calendar days after admission to the unit, excluding pts with history of colonization or infection • Denominator – 100 pt admissions (incidence); 1000 pt days ( I. density) • Surveillance interval – Monthly • Location of use – Specific units (consider use for whole HCF)
  31. 31. 5. Quantifying Healthcare Acquisition B. Metrics: Incidence or incidence density rate of hospital onset MDRO Provides a more useful metric than incidence based on clinical culture data, if conducting routine AST
  32. 32. 5. Quantifying Healthcare Acquisition B. Incidence or incidence density rate of hospital onset MDRO • Type of microbiology data required – Clinical culture and AST data • Numerator – Number of first MDRO isolated per pt per unit > 3 calendar days after admission to the unit, excluding pts with history of colonization or infection • Denominator – 100 pt admissions (incidence); 1000 pt days ( I. density) • Surveillance interval – Monthly • Location of use – Specific units (consider use for whole HCF)
  33. 33. Category of Measure Basic or measure Advanced Tracking Line Listing B Susceptibility pattern Antibiogram B Infection Burden Proxy Nosocomial MRSA B Bacteremic incidence Nosocomial MRSA A infection incidence MRSA device or procedure A associated infection
  34. 34. Category of Measure Basic or measure Advanced Exposure Burden Overall MRSA prevalence A based on clinical cultures Overall prevalence with Active Surveillance Testing A MRSA admission prevalence A Point prevalence survey A Healthcare acquisition MRSA incidence based on B (MRSA) clinical cultures A Incidence based on AST A
  35. 35. These metrics are for monitoring of MDROs burden in house and monitoring response to interventions within the healthcare facility. Should not be used for inter facility comparisons
  36. 36. Thank you for your attentionThank you for your attention

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