This document outlines a prevention strategy for multidrug-resistant organisms (MDROs) in healthcare settings. It discusses key components such as developing infection control guidelines, surveillance programs, antimicrobial stewardship, and continuous education. Control interventions include administrative support, education, judicious antimicrobial use, surveillance, standard/contact precautions, and environmental measures applied in combination based on the situation.

1. PREVENTION STRATEGY FOR
MDRO IN HOSPITAL
Dr. Moustapha Ramadan
Fellow of Community Medicine Department
Faculty of Medicine
Alexandria University

2. INTRODUCTION
Mutlidrug resistant organism:
Bacterial isolate which is resistant to one or more
agents in three or more different classes of
antimicrobials that the isolate is expected to be
susceptible to; e.g., penicillins, cephalosporins,
aminoglycosides, fluoroquinolones and
carbapenems.

3. INTRODUCTION
 Transmission of MDROs tends to occur most
frequently in acute care facilities, although all
healthcare facilities may be affected.
 The severity and extent of disease caused by the
resistant pathogens may vary by the population
affected and also by the type of healthcare facility.

4. INTRODUCTION
Factors aid that the transmission and persistence of
resistant strains in the environment:
 The presence of vulnerable patients, and those who have
indwelling devices including endotracheal tubes, vascular
catheters or urinary catheters
 The reservoir of infected or colonized patients
 The selective pressure exerted by antimicrobial use
 The effectiveness of local infection prevention and control
measures

5. KEY COMPONENTS OF A NATIONAL STRATEGY
PROGRAM IN HEALTHCARE SETTINGS
 Development of infection control guidelines for
MDRO
 Development of national Surveillance program for
MDRO infection rate
 Monitoring of adherence to local guidelines and
protocols.
 Establishment of antimicrobial stewardship
programs

6. KEY COMPONENTS OF A NATIONAL STRATEGY
PROGRAM IN HEALTHCARE SETTINGS
 National typing studies to establish the
epidemiology of MDRO.
 Establishment of a national reference laboratory
service for MDRO.
 Continuous education programs in infection
prevention and control.
 Good communication structures between
healthcare facilities.

7. CONTROL INTERVENTIONS
 Administrative support
 Education program
 judicious use of
antimicrobials
 Surveillance
 Standard and contact
precautions
 Environmental
measures
Different interventions are applied in stepwise fashion
in various combinations and in different degrees of
intensity.

8. ADMINISTRATIVE SUPPORT
 Enforcing adherence to recommended infection
control practices (e.g., hand hygiene, Standard and
Contact Precautions) for MDRO control.
 Providing the necessary number and appropriate
placement of hand washing sinks and alcohol-
containing hand rub dispensers in the facility.
 Maintaining staffing levels appropriate to the
intensity of care required.

9. ADMINISTRATIVE SUPPORT
 Implementing system changes to ensure prompt
and effective communications e.g., computer alerts
to identify patients previously known to be
colonized/infected with MDROs
 Direct observation with feedback to HCP on
adherence to recommended precautions and
keeping HCP informed about changes in
transmission rates.

10. ADMINISTRATIVE SUPPORT
 Participation in existing, or the creation of new,
regional or national coalitions, to combat
emerging or growing MDRO problem.

11. EDUCATION PROGRAMS
Facility-wide, unit-targeted.
The focus of the interventions is to encourage a
behavior change in:
 hand hygiene,
 antimicrobial prescribing patterns.

12. JUDICIOUS USE OF ANTIMICROBIAL AGENTS.
Limiting antimicrobial use alone may fail to control
resistance due to:
 The relative effect of antimicrobials on providing
initial selective pressure, compared to perpetuating
resistance once it has emerged;
 inadequate limits on usage; or
 insufficient time to observe the impact of this
intervention.

13. JUDICIOUS USE OF ANTIMICROBIAL AGENTS.
Antimicrobial prescribing patterns should be:
 Narrow spectrum agents,
 Towards treating infections and not contaminants,
 short duration of therapy,
 and restricting use of broad-spectrum or more
potent antimicrobials to treatment of serious
infections when the pathogen is not known or when
other effective agents are unavailable.

14. JUDICIOUS USE OF ANTIMICROBIAL AGENTS.
Strategies for influencing antimicrobial prescribing
patterns within healthcare facilities are best
accomplished through an organizational,
multidisciplinary, antimicrobial management
program.

15. JUDICIOUS USE OF ANTIMICROBIAL AGENTS.
The strategy includes:
 education;
 formulary restriction;
 prior-approval programs, including pre-approved
indications;
 automatic stop orders;
 academic interventions to counteract
pharmaceutical influences on prescribing patterns;
 antimicrobial cycling;
 active efforts to remove redundant antimicrobial
combinations.

16. MDRO SURVEILLANCE.
Surveillance is a critically important component of
any MDRO control program, allowing detection of
newly emerging pathogens, monitoring
epidemiologic trends, and measuring the
effectiveness of interventions.

17. SURVEILLANCE FOR MDROS ISOLATED FROM ROUTINE
CLINICAL CULTURES.
 The simplest form of MDRO surveillance
 Detect emergence of new MDROs not previously
detected.
 Used to prepare facility- or unit-specific summary
that describes pathogen-specific prevalence of
resistance among clinical isolates.

18. SURVEILLANCE FOR MDROS ISOLATED
FROM ROUTINE CLINICAL CULTURES.
 Used to calculate measures of incidence of MDRO
isolates in specific populations or patient care
locations (e.g. new MDRO isolates/1,000 patient
days, new MDRO isolates per month).
 They do not distinguish colonization from infection,
and so do not fully demonstrate the burden of
MDRO-associated disease.

19. MDRO INFECTION RATES
 Semi active surveillance strategy
 This strategy requires investigation of clinical
circumstances surrounding a positive culture
to distinguish colonization from infection.

20. SURVEILLANCE FOR MDROS BY DETECTING
ASYMPTOMATIC COLONIZATION
Is the use of active surveillance cultures (ASC) to identify
patients who are colonized with a targeted MDRO.
Requirements:
1) personnel to obtain the appropriate cultures
2) microbiology laboratory personnel to process the
cultures
3) mechanism for communicating results to caregivers
4) concurrent decisions about use of additional isolation
measures triggered by a positive culture (e.g.
Contact Precautions)
5) mechanism for assuring adherence to the additional
isolation measures.

21. SURVEILLANCE FOR MDROS BY DETECTING
ASYMPTOMATIC COLONIZATION
The target populations targeted for ASC :
 Critical location (e.g. ICU, NICU, Burn unit…)
 antibiotic exposure history,
 presence of underlying diseases,
 prolonged duration of stay,
 exposure to other MDRO colonized patients,
 patients transferred from other facilities known to
have a high prevalence of MDRO carriage,
 history of recent hospital or nursing home stays
 admitted to units experiencing high rates of
colonization/infection with the MDROs of interest

22. INFECTION CONTROL PRECAUTIONS
Standard Precautions:
1. HAND HYGIENE
2. Personal protective equipment
3. Aseptic technique- Prevention of needle stick
4. Environmental Cleaning
5. Instruments reprocessing
6. Waste management
Universal precautions:
Blood spillage management/ blood and body fluid
post exposure management

23. INFECTION CONTROL PRECAUTIONS.
 Transmission Based precaution- Contact
precautions
are intended to prevent transmission of infectious
agents which are transmitted by direct or indirect
contact with the patient or the patient’s environment.
HCP caring for patients on Contact Precautions should
wear a gown and gloves for all interactions that may
involve contact with the patient or potentially
contaminated areas in the patient’s environment.

24. INFECTION CONTROL PRECAUTIONS.
Ideally, every patient who is colonised or infected with
MDRO should be isolated in a single room with en-
suite facilities.
The patient’s healthcare records should be flagged to
highlight the positive MDRO status.
Cohorting of patients, cohorting of staff, use of
designated beds or units, and even unit closure
maybe necessary to control transmission.

25. INFECTION CONTROL PRECAUTIONS.
The highest priority for isolation should be given to
those patients who have conditions which may
facilitate transmission of an MDRO, i.e. those with
uncontained excretions or secretions such as:
• Diarrhoea
• Draining wounds
• Incontinence of urine or faeces
• Copious respiratory secretions

26. INFECTION CONTROL PRECAUTIONS.
 The movement of patients with MDRO within a
facility should be kept to a minimum to reduce the
risk of cross infection.
 When patients need to attend departments for
essential investigations or procedures, the
receiving area should be notified of the patient’s
MDRO status in advance of transfer and adopt
Contact Precautions when caring for the patient.

27. INFECTION CONTROL PRECAUTIONS.
 Duration of Contact Precautions remains an
unresolved issue.
 In general, it seems reasonable to discontinue
Contact Precautions when three or more negative
cultures for the target MDRO in the absence of a
draining wound, profuse respiratory secretions, or
evidence implicating the specific patient in ongoing
transmission of the MDRO within the facility.

28. ENVIRONMENTAL MEASURES.
 Assignment of dedicated cleaning personnel to the
affected patient care unit.
 Increased cleaning and disinfection of frequently-
touched surfaces (e.g., bedrails, charts, bedside
commodes, doorknobs).
 Monitoring adherence to recommended
environmental cleaning practices.
 Environmental cultures are not routinely
recommended