This document discusses multidrug-resistant organisms (MDROs) and strategies for preventing their transmission in healthcare settings. It defines MDROs as microorganisms resistant to more than 2 classes of antibiotics. Examples mentioned include methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase producing Klebsiella and E. coli, and multidrug-resistant Acinetobacter and Pseudomonas. Risk factors for MDRO acquisition include prolonged hospitalization, antibiotic use, and invasive devices/procedures. Transmission occurs via contact with patients or contaminated surfaces/equipment. Containment requires infection control measures like isolation, cleaning, and prudent antibiotic use.

2.  Alert organisms = MDRO

3.  Microorganisms that are resistant to more
than 2 classes of antibiotics.
 These organism potentially can cause
outbreaks
CDC: Management of Multidrug-Resistant Organisms in Healthcare Settings, Healthcare Infection Control Advisory Committee, Jane D. Siegel et. al. pg 7-12

4. B-lactam
- Penicillin
- Ampicillin
- Cephalosporin
- Carbapenem
Aminoglycoside
- Amikacin
- Gentamicin
- Netilmicin
Quinolones
- Ciprofloxacin
- Levofloxacin
- Moxifloxacin
- Gatifloxacin
Macrolide
- Erythromycin
- Azithromycin
- Clarithromycin
Glycopeptide
- Vancomycin
-Teicoplanin
Oxazolinidanone
- Linezolid
Glycylcycline
- Tigecycline
Sulpha drugs
- Trimethoprim-
sulfamethoxazole
(Bactrim)
Lincosamide
- Clindamycin
Tetracycline
-Tetracycline
- Doxycycline
Cyclic peptide
- Polymyxin

5. New Resistant Bacteria
Susceptible Bacteria
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Resistant Bacteria
Resistance Gene Transfer

6. Resistant Strains
Rare
Resistant Strains
Dominant
Antimicrobial
Exposure
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

7.  Preventing drug entry by
altering cell permeability;
 Preventing the drug from
reaching the target site
by trapping it within the
cell or pumping it back
out (efflux pumps);
 Inactivating or modifying
the drug by using
enzymes;
 Altering the drug target
site.

9. 1. Methicillin-Resistant Staph aureus
(MRSA)
2. Extended Spectrum Beta-Lactamase
producing Klebsiella pneumoniae &
Escherichia coli. (ESBLs)
3. Multidrug Resistant Acinetobacter sp.
& Pseudomonas aeruginosa

10.  VRE (Vancomycin Resistant Enterococcus)
 CREs (Carbapenemase Resistant
Enterobacteriacea )
- KPC (Klebsiella producing carbapenemase)
- NDM-1 (New-Delhi metallobetalactamase)

11. Enterococcus faecium
Staphylococcus aureus
Clostridium difficile
Acinetobacter baumannii
Pseudomonas aeruginosa
Enterobacteriaceae
Acknowledges the growing
virulence of C. difficile
Captures Klebsiella,
Enterobacter, and other
resistant species including
E. coli and Proteus sp.
Peterson LR Clin Infect Dis 2009, 49:992

12. 1. Use of broad spectrum antibiotics (esp.ly 2nd & 3rd gen.
cephalosporin).
2. Patients with severe underlying disease and who are
chronically debilitated
3. Immunocompromised and patients with extensive burns
4. Critically ill patients with prolonged hospital stay,
especially in ICU, oncology, transplant and burn wards
5. Presence of indwelling devices – IV lines, CBD, ETT,
surgical drains, PEG tubes, gastrostomy tube
6. Patients undergo intra-abdominal, cardiothoracic,
orthopaedic, vascular and urological procedures/surgery

13.  Ventilator-associated pneumonia
 Urinary tract infection
 Bloodstream infection
 Skin/wound infections
 Catheter-related infections

14.  Increased:
› Length of stay
› Admissions to ICU
› Invasive/Surgical procedures
› More tests
› Cost
› Morbidity
› Mortality
14
http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

15. Methicillin
Resistant
Staphylococcus
aureus

16. S. aureus
Penicillin
[1950s]
Penicillin-resistant
S. aureus
 Link to: CDC Facts about VISA  Link to: CDC Facts about VRE
Methicillin
[1970s]
Methicillin-
resistant
S. aureus (MRSA)
Vancomycin-resistant
enterococci (VRE)
Vancomycin
[1990s]
[1997]
Vancomycin
intermediate-
resistant
S. aureus
(VISA)
[ 2002 ]
Vancomycin-
resistant
S. aureus
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 9: Know when to say “no” to vanco
 Link to: MMWR on VRSA

17. 0
0.05
0.1
0.15
0.2
0.25
0.3
Percentage
National MRSA Trends, 2007-2012
0.19
0.19
0.16
0.13
0.11 0.11

18. Staphylococcus aureus
Antibiotic Sensitivity
Cloxacillin S
Erythromycin S
Bactrim S
Gentamicin S
Fusidic acid S
Rifampicin S
Vancomycin S
Linezolid S
Antibiotic Sensitivity
Cloxacillin R
Erythromycin R
Bactrim R
Gentamicin R
Fusidic acid S/R
Rifampicin S/R
Vancomycin S
Linezolid S
Antibiotic sensitivity pattern
MRSA

19.  Contact –
› direct – It spreads most commonly on HCW’s hands.
› Indirect – inanimate objects
 MRSA can live for hours, up to days on
surfaces
› Linen, clothes
› Bedrail, bedside tables

21. - Enzyme produced by bacteria
- Break down beta-lactam ring
- ‘Extended’ = capable to inactivate
third-generation cephalosporin
(ceftazidime, cefoperazone,
cefotaxime) and monobactam

22. Plasmid-mediated TEM and SHV -lactamases
Ampicillin
1965
TEM-1
E.coli
S.paratyphi
1970s
TEM-1
Reported in
28 Gm(-) sp
1983
ESBL in
Europe
1988
ESBL
in USA
2000
> 130 ESBLs
Worldwide
Extended-spectrum
Cephalosporins
1963
Evolution of -Lactamases
22

23.  Klebsiella pneumoniae
 Escherichia coli
 Proteus mirabilis

24.  Enterobacteriaceae
› Citrobacter, Enterobacter
› Morganella morganii, other Proteus, Providencia
stuartii, Salmonella, Serratia marcescens,
Shigella
 Other Organisms
› Pseudomonas aeruginosa, Acinetobacter
baumannii, Aeromonas hydrophila, Burkholderia
cepacia, Vibrio cholerae

25.  Gram-negative Organisms (GNB)
 Resistant to cephalosporin group
 Sensitive to Carbapenem – Imipenem,
Meropenem, Ertapenem
 Drug of choice for treatment : Carbapenem

26. ANTIBIOTIC SENSITIVITY
Cephalothin (Ceporex) R
Cefuroxime (Zinacef/Zinnat) R
Ceftriaxone (Rocephine) R
Ceftazidime (Fortum) R
Cefoperazone (Cefobid) R
Cefotaxime (Claforan) R
Cefepime (Maxipime) R
Imipenem (Tienem) S
Meropenem (Meronem) S
Ertapenem S

27.  Important nosocomial
pathogen
 Aerobic, motile Gram-
negative rod
 Isolated from soil,
water, plants, human
and animal

28.  Predominantly moisture-associated
1. Sinks
2. Showers
3. Respiratory equipment
4. Intravenous fluids
5. Disinfectants
6. Tracheal irrigate
 Inadequately disinfect or sterilized endoscopes

30. Antibiotic Sensitivity
Ceftazidime R
Cefepime R
Unasyn R
Sulperazone R
Imipenem R
Meropenem R
Ciprofloxacin R
Tazocin R
Polymyxin B S

31.  Gram negative organisms
 Ubiquitous:
› Widely distributed in nature (soil, water, food, sewage)
& the hospital environment
 Survive on moist & dry surfaces
 Highly antibiotic resistant ( Only sensitive to
Polymyxin B)

32.  Bed rails
 Bedside tables
 Ventilators
 Infusion pumps
 Mattresses
 Pillows
 Air humidifers
 Patient monitors
 X-ray view boxes
 Curtain rails
 Curtains
 Equipment carts
 Sinks
 Ventilator circuits
 Floor mops
 Heparinised saline
solution

34.  Normal flora in human gastrointestinal system
 Aerobic, Gram-positive cocci in chain
 Low virulence
 Inherently resistant to cephalosporin
 Commonly cause urinary tract infection,
bloodstream infection or surgical site infection.

35. Antibiotic Sensitivity
Ampicillin S
Gentamicin S
Vancomycin S
Linezolid S
Antibiotic Sensitivity
Ampicillin R
Gentamicin R
Vancomycin R
Linezolid S
Enterococcus sp.
Vancomycin
Resistant
Enterococcus

36. Carbapenem resistant
enterobacteriaceae
(CRE)

37.  CRE are defined as Enterobacteriaceae that
are
› intermediate or resistant to one or more
carbapenems using the current CLSI interpretive
criteria AND
› Resistant to all of the following third-generation
cephalosporins that were tested: ceftriaxone,
cefotaxime, and ceftazidime.
Guidance for control CRE. CRE toolkit 2012. CDC

38.  production of carbapenemases mainly coded
by ten different genes namely, SME, NMC,
IMI, GES, KPC, IMP, VIM, NDM, KHM and
OXA,
 SME and NMC - chromosomal mediated
 Others- plasmid mediated having potential
for the transmission to other bacteria
Sekar R, Mythreyee M (2012) Carbapenem Resistant Enterobacteriaceae – A
Growing Threat to Public Health. 1:324.

39.  2010 – 1 case ( patient transfer from HSAJB)
 2011 – 22 cases
 May 2012 – 204 cases
 2013 – 377
 2014….427

40. TRENDING OF CRE CASES, 2011-2014
N =
427
Infection Control Unit, Medical Care Quality Section, Medical Development Division, MOH
0
100
200
300
400
500
Year 2011 Year 2012 Year 2013 Year 2014
28
204
377 427
Frequency

41.  Disk diffusion
 MIC
 Molecular confirmation
by PCR

42.  When to suspect
1. Resistant to one of the carbapenem group
(ertapenem/imipenem/meropenem
/doripenem)
2. And resistant to all cephalosporins
 Ertapenem is a good indicator. Imipenem is
not a good indicator

43. Gupta N et al. Carbapenem resistant enterobacteriaceae. Epidemiology
and Prevention. Clinical Infectious Diseases 2011;53(1):60–67

47.  Availability to alcohol hand rub, hand
washing sinks, PPE
 Patient Safety Goal
 Adherence to hand hygiene - audit

48. HAND HYGIENE

49. Compliance > 75%

50.  Training
 CME
 Courses
 Road-show
 HH week

52.  Avoid misuse/inappropriate use of
antibiotics:
› use of antibiotics to treat viral infections
› use of antibiotics to treat colonization, symptomatic infections
› use of prophylactic antibiotics for more than 48 hours
postoperatively (McDermott et al., 1997)
› empiric treatment of infections rather than obtaining cultures

53.  Microorganisms which do not belong to the
normal flora of the host but do not inflict local
damage to the host
 An agent is considered to colonize a host
when its presence in that host does not
cause a specific immune response or
 infection

54.  A process in which an organism enters,
establishes itself, and multiplies in the host
resulting in disease

55.  Antibiotic stewardship program: designed
to improve prescribing
› Guidelines/ policies
› Education/seminars
› Prescribing strategies- antibiotic stop order,
cycling, restriction

56.  Lab based surveillance - Incidence based on
clinical culture results
 Targeted infection in specific patient
population / units e.g ICU

57.  Contact Isolation
 To prevent the spread of infection
 To place the infectious patient on special
precautions
 Cohorting

58.  Dedicated noncritical medical equipment
 Assignment of dedicated cleaning personnel
 Increasing cleaning and disinfectant of
frequently touched surfaces (bedrails,
doorknobs)
 Waste disposal

59. EVERYBODY’S
RESPONSIBILITIES