Management of Multi-Drugs Resistant Organisms presented by SN Lieza from Orange Valley Nursing Home (Marsiling)

1. Management of
Multi- Drugs
Resistant
Organisms

2. • MDROs refer to a group of bacteria which is
resistant to one or more agents in three or more
different classes of antimicrobials.
• Examples: Penicillins, Cephalosporins,
Aminoglycosides, Fluoroquinolones and Carbapenems).
• Main mode of all MDROs transmission is through:
1) Direct and indirect contact with infected or
colonized patients.
2) For MRSA sputum, it can also be spread through
droplets.
Definition of MDROs

3. a) Methicillin-resistant Staphylococcus aureus (MRSA)
b) Vancomycin-resistant enterococcus (VRE)
c) Methicillin- resistant Acinetobacter (MRAB) and
d) Carbapenemase-producing carbapenem resistant
Enterobacteriaceae (CP-CRE)
o Klebsiella penrumoniae carbapenemase (KPC)
o New Delhi metallo-β-lactamase (NDM)
o Oxacillinase (OXA)
o Verona Integron-encoded metallo-β-lactamase (VIM)
o Imipenemase Metallo-beta-lactamase (IMP)
o Plasmid-mediated Colistin Resistance (MCR-1 and MCR-2)
Common Types of MDROs

4. • Infection refers to the presence of MDRO in
tissues or body fluids along with signs and symptoms
of infection (either locally or systemically).
• Colonisation refers to the presence of MDRO in
body fluids or tissues (e.g. gastrointestinal tract,
urine, or sputum) without clinical signs of infection.
Definition of Infection vs Colonisation

5. • For relatively healthy independent residents colonized with an
MDRO, isolation or cohorting is not necessary
• For ill dependent residents with an MDRO, shall be placed in cohort
room.
 Residents infected or colonized with MRSA must not be
placed next to a resident infected or colonized with VRE in
the same cubicle.
 If an isolation room or cohort area is instituted, staff shall
perform terminal cleaning of using the appropriate level of
disinfectant and left room/ area vacant to air-dry for at least
45 minutes before next use.
Placement of Residents

6. a) Pre-admission review of MDROs status so that appropriate
precautions can be prepared before arrival to nursing home
b) Perform risk assessment and screening (MDROs culture swab), if
necessary
c) Monitor MDRO culture results, if any.
d) Communicate information of resident’s MDRO status to other
receiving facilities.
e) Maintain a list of residents infected or colonized with an MDRO.
Types of Surveillance

7. a)Any new or emergent MDRO that is first identified and never before
seen in the nursing home.
b)Any MDRO cluster(s) occurring within the nursing home that involves
an emerging or new MDRO.
c)Any MDRO cluster(s) occurring within the nursing home that are
deemed not manageable by the nursing home.
d)Any outbreak involving the nursing home, whether this involves an
endemic or emerging/ new MDRO, which may or may not involve other
healthcare facilities,
e)Any cluster(s) or outbreak(s) involving the healthcare facility, for
which the source is traced to an external source.
When to Escalate

8. • All CP-CRE and VRE cases should not be untagged under any
circumstances.
• Untagging residents with a past history of MRSA positivity with
the consult of medical practitioner, if the resident has met one
of the following criteria:
• For clearance of MRSA : 3 rounds of negative
swab result for Nasal, Axillae and Groin screening
cultures
• At least 1 day apart between each round of
swabbing
Tagging and Untagging of MDROs status

9. • Use a sterile culture swab with medium to obtain the
specimen.
• If culture swab with medium is not available, then use a
sterile standard culture swab and moisten with sterile
water/ saline.
• Label specimens with the site of sample before sending
to the laboratory.
Collection of Specimens

10. Collecting swab for MRSA (Nasal, Axilla and Groin)
• Prepare 2 swab sticks.
• 1st swab stick: Swab bilateral nostrils.
• 2nd swab stick: Swab bilateral axilla and groin region.
• Rotate culture swab 3 times on each area
• Return the culture swab to its container.
• Label the specimen with resident’s sticky label and fill up
the laboratory request form accordingly.
Collection of Specimens (MRSA)

11. Collecting rectal swab for VRE
• Insert the culture swab approximately 2.5cm into the
rectum and gently rotate in a clockwise / counter-
clockwise direction.
• Return the culture swab to its container.
• Label the specimen with resident’s sticky label and fill
up the laboratory request form accordingly.
Collection of Specimens (VRE)