1. Multidrug-Resistant Nosocomial Infections in the PICU : how to deal with it?
Somchai Suntornlohanakul

2. Scope of Presentation Introduction & Background of MDRO
Epidemiology of MDRO
MDRO prevention and control
Preventing nosocomial infection in PICU: practical point for Nurse

3. Multidrug-Resistant Nosocomial Infections in the PICU : how to deal with it?
Multidrug-resistant organisms (MDRO), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and certain Gram-negative bacill (GNB) have important infection control implications
The prevention and control of MDRO is a national priority

4. The prevention and control of MDRO
is a national priority
The administration of healthcare organizations and institutions should ensure that
appropriate strategies are fully implemented
regularly evaluated for effectiveness
adjusted such that there is a consistent decrease in the incidence of targeted MDRO

5. Successful prevention and control of MDRO
Scientific Leadership
Financial Support
Administrative Leadership
Human Resource Commitment
Resources should include expert consultation, laboratory support, adherence monitoring, and data analysis

6. Infection prevention and control professionals have found that healthcare personnel (HCP) are more receptive and adherent to the recommended control measures when organizational leaders participate in efforts to reduce MDRO transmission

7. Multidrug-Resistant Organisms
MDRO are defined as microorganisms, predominantly
bacteria, that are resistant to one or more classes of
antimicrobial agents.
Although the names of certain MDRO describe resistance to
only one agent (e.g., MRSA, VRE, [ESBL]-producing or
intrinsically resistant Gram-negative bacilli), these pathogens
are frequently resistant to most available antimicrobial agents

8. Clinical importance of MDRO
In most instances, MDRO infections have clinical manifestations that are similar to infections caused by susceptible pathogens
Options for treating patients with these infections are often extremely limited
Increased lengths of stay, costs, and mortality also have been associated with MDRO

9. MRSA and MSSA MRSA may behave differently from other MDRO
MRSA colonized patients more frequently develop symptomatic infections
Higher case fatality rates have been observed for certain MRSA infections, including bacteremia, poststernotomy mediastinitis, and surgical site infections

10. Epidemiology of MDRO
Prevalence of MDRO varies temporally, geographically,
and by healthcare setting
The type and level of care also influence the prevalence
of MDRO
Antimicrobial resistance rates are also strongly
correlated with hospital size, tertiary-level care, and
facility type

11. Epidemiology of MDRO
Prevalence of target MDRO in the adult patient is greater than pediatric population.
Point prevalence surveys conducted by the Pediatric Prevention Network (PPN) in eight U.S. PICU and 7 U.S. NICU in 2000:
< 4% of patients were colonized with MRSA or VRE
10-24% were colonized with ceftazidime- or aminoglycoside-resistant Gram-negative bacilli
< 3% were colonized with ESBL-producing Gram negative bacilli.
MDRO burden is greatest in adult hospital patients, but require similar control efforts

12. Important concepts in transmission
Transmission and persistence of the resistant strain is determined by
the availability of vulnerable patients
selective pressure exerted by antimicrobial use
increased potential for transmission from larger numbers of colonized or infected patients (“colonization pressure”)
impact of implementation and adherence to prevention efforts

13. Important concepts in transmission
Ample epidemiologic evidences suggest that MDRO are carried from one person to another via the hands of HCP
Without adherence to recommendations for hand hygiene and glove use, HCP are more likely to transmit MDRO to patients
Strategies to increase and monitor adherence are important components of MDRO control programs

14. Role of colonized HCP in MDRO transmission
Rarely, HCP may introduce an MDRO into a patient care unit
Occasionally, HCP can become persistently colonized with an MDRO, but these HCP have a limited role in transmission, unless other factors are present.
Factors that can facilitate transmission, include chronic sinusitis, upper respiratory infection, and dermatitis

15. MDRO Prevention and Control

16. MDRO Prevention of Infections
Campaign to Reduce Antimicrobial Resistance in Healthcare Settings
A multifaceted, evidence-based approach with four parallel strategies:
infection prevention
accurate and prompt diagnosis and treatment
prudent use of antimicrobials
prevention of transmission

17. Prevention and Control of MDRO transmission
Successful control of MDRO has been documented in the
US and abroad using a variety of combined interventions
Hand hygiene
Contact Precautions
Active surveillance cultures (ASC)
Education
Enhanced environmental cleaning
Improvements in communication about patients with MDRO within and between healthcare facilities

19. Control Interventions
Administrative support
MDRO Education
Judicious Antimicrobial Use
MDRO Surveillance
Infection Control Precautions to Prevent Transmission
Environmental Measures
Decolonization

20. Administrative Support
Implementing system changes to ensure prompt and effective communications
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

21. Administrative Support
Enforcing adherence to recommended infection control practices for MDRO control
Adherence monitoring
Participation in regional or national coalitions to combat emerging or growing MDRO problems

22. Control Interventions
Administrative support
MDRO Education
Judicious Antimicrobial Use
MDRO Surveillance
Infection Control Precautions to Prevent Transmission
Environmental Measures
Decolonization

23. MDRO Education
Encourage a behavior change through improved understanding of the problem MDRO that the facility was trying to control
Facility-wide, unit-targeted, and informal, educational interventions
Patient outcomes
Antibiotic choice & Resistance
Infection control

24. Control Interventions
Administrative support
MDRO Education
Judicious Antimicrobial Use
MDRO Surveillance
Infection Control Precautions to Prevent Transmission
Environmental Measures
Decolonization

25. Pharmacokinetic (PK)/Pharmacodynamic (PD) considerations
The goal of antibiotic therapy is to achieve complete bacterial eradication and to minimise the risk of resistance selection
The dosing regimen is influenced by its PK profile and the susceptibility of the target pathogen
To predict bacteriological and clinical efficacy and help to identify the correct dose and dosing interval

26. Judicious Antimicrobial Use
Focus on effective antimicrobial treatment of infections
Use of narrow spectrum agents
Treatment of infections and not contaminants
Avoiding excessive duration of therapy
Restricting use of broad-spectrum or more potent antimicrobials to treatment of serious infections when the pathogen is not known

27. Strategies for influencing antimicrobial prescribing patterns
Education
Formulary restriction
Prior-approval programs
Automatic stop orders
Academic interventions to counteract pharmaceutical influences on prescribing patterns
Computer-assisted management programs
Active efforts to remove redundant antimicrobial combinations

28. Control Interventions
Administrative support
MDRO Education
Judicious Antimicrobial Use
MDRO Surveillance
Infection Control Precautions to Prevent Transmission
Environmental Measures
Decolonization

29. MDRO surveillance
Surveillance is a critically important component of any MDRO control program
allowing detection of newly emerging pathogens
monitoring epidemiologic trends
measuring the effectiveness of interventions
MDRO surveillance strategies
surveillance of clinical microbiology laboratory results obtained as part of routine clinical care
active surveillance cultures (ASC) to detect asymptomatic colonization

30. 1: Surveillance for MDRO Isolated from routine clinical cultures
1.1 Antibiograms
1.2 MDRO Incidence Based on Clinical Culture Results
1.3 MDRO Infection Rates
1.4 Molecular typing of MDRO isolates

31. 1.1 Antibiograms
Monitoring of clinical microbiology isolates resulting from tests ordered as part of routine clinical care
Detect emergence of new MDRO
Prepare facility- or unit-specific summary antimicrobial susceptibility reports that describe pathogen-specific prevalence of resistance among clinical isolates
Useful to monitor for changes in known resistance patterns
Provide clinicians with information to guide antimicrobial prescribing practices

32. 1.2 MDRO Incidence Based on Clinical Culture Results
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)
Useful for monitoring MDRO trends and assessing the impact of prevention programs
Based solely on positive culture results without accompanying clinical information

33. MDRO Incidence Based on Clinical Culture Results
Do not distinguish colonization from infection
Culture obtained from a patient several days after admission to a given unit or facility does not establish that the patient acquired colonization in that unit
Acquire MDRO colonization may remain undetected by clinical cultures

34. MDRO Incidence Based on Clinical Culture Results
Despite limitations, incidence measures were highly correlated with actual MDRO transmission rates derived from information using ASC
The results suggest that incidence measures based on clinical cultures alone might be useful surrogates for monitoring changes in MDRO transmission rates

35. 1.3 MDRO Infection Rates
Requires investigation of clinical circumstances surrounding a positive culture to distinguish colonization from infection
Can be particularly helpful in defining the clinical impact of MDRO within a facility

36. 1.4 Molecular typing of MDRO isolates
Many investigators have used molecular typing
of selected isolates to confirm clonal transmission
to enhance understanding of MDRO transmission
and the effect of interventions within their facility

37. 2. Surveillance for MDRO by Detecting Asymptomatic Colonization
Active Surveillance Cultures (ASC) to identify patients who are colonized with a targeted MDRO
Based upon that, for some MDRO, detection of colonization may be delayed or missed completely if culture results obtained in the course of routine clinical care

38. Use of ASC incorporated into MDRO prevention programs
Support for successful implementation includes
personnel to obtain the appropriate cultures
microbiology laboratory personnel to process the cultures
mechanism for communicating results to caregivers
concurrent decisions about use of additional isolation measures triggered by a positive culture (e.g. Contact Precautions)
mechanism for assuring adherence to the additional isolation measures

39. Populations targeted for ASC
Not well defined
High risk for MDRO colonization based on
location (e.g. PICU with high MDRO rates)
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, or having a history of recent hospital or nursing home stays
All patients admitted to units experiencing MDRO colonization

40. Optimal timing and interval of ASC
Not well defined
Cultures were obtained at the time of admission to the hospital or intervention unit
Some obtain cultures on a periodic basis to detect silent transmission
Some based follow-up cultures on the presence of certain risk factors for MDRO colonization

41. Methods for obtaining ASC
Must be carefully considered, and vary depending upon the MDRO of interest
MRSA: cultures of the nares, peri-rectal and wound cultures can identify additional carriers
VRE: Stool, rectal, or peri-rectal swabs
MDR-GNB: peri-rectal or rectal swabs alone or in combination with oro-pharyngeal, endotracheal, or wound cultures
The absence of standardized screening media for many Gram negative bacilli can make the process of isolating a specific MDR-GNB a relatively labor-intensive process

42. Rapid detection methods
Using conventional culture methods can result in a delay of 2-3 days and the desired infection control measures could be delayed.
If empiric precautions are used pending negative surveillance culture results, precautions may be unnecessarily implemented.

43. Control Interventions
Administrative support
MDRO Education
Judicious Antimicrobial Use
MDRO Surveillance
Infection Control Precautions to Prevent Transmission
Environmental Measures
Decolonization

44. Infection Control Precautions
Standard Precautions
Contact Precautions
Cohorting and other MDRO control strategies
Duration of Contact Precautions
Impact of Contact Precautions on patient care and well-being

45. Standard Precautions An essential role in preventing MDRO transmission
Colonization with MDRO is frequently undetected
Standard Precautions must be used to prevent transmission from potentially colonized patients
Hand hygiene is an important component of Standard Precautions

46. Contact Precautions
Prevent transmission of infectious agents transmitted by direct or indirect contact with the patient or the patient’s environment
A single-patient room is preferred
When a single-patient room is not available, consultation with infection control is necessary to assess the various risks associated with other patient placement options

47. Contact Precautions
HCP 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
Donning gown and gloves upon room entry and discarding before exiting the patient room is done

48. Cohorting and other MDRO control strategies
Cohorting of patients
Cohorting of staff
Use of designated beds or units, unit closure were necessary to control transmission

49. Duration of Contact Precautions
Remains an unresolved issue
In the context of an outbreak, prudence would dictate that Contact Precautions be used indefinitely for all previously infected and known colonized patients

50. Duration of Contact Precautions
If ASC are used to detect and isolate patients colonized with MRSA or VRE
There is no decolonization of these patients
Contact Precautions would be used for the duration of stay in the setting where they were first implemented

51. Duration of Contact Precautions
In general, discontinue contact precautions when
three or more surveillance cultures for MDRO are repeatedly negative
over the course of a week or two in a patient who has not received antimicrobial therapy for several weeks
in the absence of a draining wound, profuse respiratory secretions

52. Impact of Contact Precautions on patient care and well-being
HCP, attending physicians, were half as likely to enter the rooms of or examine patients on contact precautions
Had significantly more preventable adverse events
Increased anxiety and depression scores
Expressed greater dissatisfaction with their Rx
Efforts must be made by the healthcare team to counteract these potential adverse effects

53. Control Interventions
Administrative support
MDRO Education
Judicious Antimicrobial Use
MDRO Surveillance
Infection Control Precautions to Prevent Transmission
Environmental Measures
Decolonization

54. Contaminated surfaces increase cross-transmissionx x x x x x x x x

55. Control Interventions
Administrative support
MDRO Education
Judicious Antimicrobial Use
MDRO Surveillance
Infection Control Precautions to Prevent Transmission
Environmental Measures
Decolonization

56. Decolonization
Decolonization entails treatment of persons colonized with a specific MDRO, usually MRSA, to eradicate carriage of that organism
Decolonization regimens are not sufficiently effective to warrant routine use

57. Decolonization Factor that limit the utility of decolonization
Identification of candidates requires surveillance cultures
Candidates receiving the treatment must receive follow-up cultures to ensure eradication
Re-colonization with the same strain and emergence of resistance to treatment can occur

58. Other Questions
Impact on other MDRO from interventions targeted to one MDRO
Costs
Feasibility
Factors that influence selection of MDRO control measures
Differences of opinion on the optimal strategy to control MDRO

59. Factors that influence selection of MDRO control measures
No single approach to the control of MDRO is appropriate for all healthcare facilities
Factors influence the choice of interventions to be applied within an institution, including
Type and significance of problem MDRO within the institution
Population and healthcare-settings

60. Selection of interventions for controlling MDRO transmission should be based on assessments of the local problem, the prevalence of various MDRO and feasibility
Individual facilities should seek appropriate guidance and adopt effective measures that fit their circumstances and needs

61. Intensification of MDRO control activities
Problem Assessment
Evaluate the Effectiveness of measures
Governing body and medical staff
Select appropriate additional control measures
Expert
Intervention Implementation
On going Surveillance