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The Alan D. Junkins, PhD, D(ABMM) of Multi- Drug- Resistant Organisms Sponsored by an educational grant from Louisville, KY.

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Presentation on theme: "The Alan D. Junkins, PhD, D(ABMM) of Multi- Drug- Resistant Organisms Sponsored by an educational grant from Louisville, KY."— Presentation transcript:

1 The Alan D. Junkins, PhD, D(ABMM) of Multi- Drug- Resistant Organisms Sponsored by an educational grant from Louisville, KY

2

3 You know that Pseudomonas aeruginosa from Mr. Jones in 5F? Is that an MDRO?

4 Why do you want to know? Why are you asking me? How should I know?

5 Why do you want to know?

6 Your own internal monitoring – “We’ve had a 35% increase in MRSA isolates this year.” For infection control purposes – “All patients with MDR GNB are placed in contact precautions.” Reporting to authorities – “We have to report all MDROs to the state.”

7 Why do you want to know? Your own internal monitoring – “We’ve had a 35% increase in MRSA isolates this year.” For infection control purposes – “All patients with MDR GNB are placed in contact precautions.” Reporting to authorities – “We have to report all MDROs to the state. Who defines MDRO? You do, Or whomever you’re producing the data for

8 Why do you want to know? Your own internal monitoring – “We’ve had a 35% increase in MRSA isolates this year.” For infection control purposes – “All patients with MDR GNB are placed in contact precautions.” Reporting to authorities – “We have to report all MDROs to the state. Who defines MDRO? Your infection control team

9 Why do you want to know? Your own internal monitoring – “We’ve had a 35% increase in MRSA isolates this year.” For infection control purposes – “All patients with MDR GNB are placed in contact precautions.” Reporting to authorities – “We have to report all MDROs to the state.” Who defines MDRO? NHSN, CDC, State, Parent Company

10 Hence, the problem… Different people doing the defining… for different reasons… …leads to different definitions.

11

12 I know one when I see one… …well, maybe not.

13 The Simplest Approach Resistant to > 1 drug classes of drugs>2 Non-susceptible to The Not Quite As Simple But Now The Closest Thing We Have to Universally Accepted Approach

14 XDR and PDR Non-susceptible to at least 1 drug in all but two or fewer classes Non-susceptible to all agents in all classes

15 What is a “class” of drugs? Beta-lactams

16 What is a “class” of drugs? Cephalosporins Penicillins Monobactams Carbapenems

17 What is a “class” of drugs? 1 st gen. Cephalosporins Aminopenicillins Monobactams Carbapenems Ureidopenicillins Carboxypenicillins ß-lactamase resistant penicillins ß-lactamase inhibitor combinations 2 nd gen. Cephalosporins 3 rd gen. Cephalosporins 4 th gen. Cephalosporins 5 th gen. Cephalosporins Cefamycins

18 What is resistance to a class? Bug ABug BBug CBug D GentamicinRRRI TobramycinRRSS AmikacinRSSS Resistant to this class?

19 What about intrinsic resistances? Should intrinsic resistance count toward number of classes showing resistance? Typically chromosomally encoded; those genetic determinants are not easily passed on to other bacteria But still can be bad boys – bad infections, bugs can be transmitted to others, hard to treat

20 If we include intrinsic resistances in our definition, then every single Acinetobacter baumannii, Burkholderia cepacia, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia we isolate would be considered MDRO.

21 If we include intrinsic resistances in our definition, then every single Morganella, Proteus, Providencia, and Serratia marcescens we isolate would be considered MDRO.

22 I’ll refer to this later as the “GBGX” paper.

23 22 drugs in 17 classes MDR – NS to at least one drug in at least 3 classes XDR – NS to at least one drug in all but 2 or fewer classes PDR – NS to all drugs in all classes

24 22 drugs in 17 classes 14 drugs in 13 classes MDR – NS to at least one drug in at least 3 classes XDR – NS to at least one drug in all but 2 or fewer classes PDR – NS to all drugs in all classes

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26 Standardization, but is it practical? OrganismWhat they suggestWhat’s on our panel Staphylococcus aureus22 drugs in 17 classes14 drugs in 13 classes Enterococcus17 drugs in 11 classes10 drugs in 8 classes Enterobacteriaceae32 drugs in 17 classes23 drugs in 14 classes Pseudomonas aeruginosa17 drugs in 8 classes11 drugs in 6 classes Acinetobacter22 drugs in 9 classes14 drugs in 8 classes MDR – NS to at least one drug in at least 3 classes XDR – NS to at least one drug in all but 2 or fewer classes PDR – NS to all drugs in all classes

27 Authors recommend additional designations: “Possible XDR” “Possible PDR”

28 January 2013 We’ll call this one the “CDC” paper. Based on 2008 SHEA/HICPAC Position Paper published in Inf Control & Hosp Epidemiol, October 2008, vol. 29, no. 10

29 ual/12pscMDRO_CDADcurrent.pdf, January 2013 MDRO Definitions Resistant to oxacillin, methicillin, or cefoxitin, or positive by an FDA-approved test for mecA on isolated colonies or in specimens Not a MRSA

30 ual/12pscMDRO_CDADcurrent.pdf, January 2013 MDRO Definitions Any Enterococcus resistant to vancomycin or positive by an FDA-approved test for VRE Any Klebsiella non-susceptible to ceftriaxone, cefotaxime, ceftazidime, or cefepime*** ***Based on new breakpoints

31 ual/12pscMDRO_CDADcurrent.pdf, January 2013 MDRO Definitions Non-susceptible to imipenem, meropenem, or doripenem***, or positive by a test for carbapenemase ***Based on new breakpoints

32 ual/12pscMDRO_CDADcurrent.pdf, January 2013 MDRO Definitions

33 Back to CRE Call this one the “CRE Toolkit” Based on new breakpoints

34 But maybe not so straightforward…

35 How many CRE at Norton*? (since January 1, 2010) True Modified Hodge Positive Standard definition from CDC’s “CRE Toolkit” Take away imipenem-NS Proteus, Providencia, Morganella Include ertapenem NS isolates *We are still using the “old” cephalosporin and carbapenem breakpoints.

36 Mandatory Reporting Which definition to use? – Labs using old breakpoints – Labs using new breakpoints Infections only, or include colonization? – Mandatory surveillance? – Which method? CDC method Chromogenic media

37 What We’ve Done Certain organisms are designated in microbiology laboratory reports as MDROs. The Microbiology Laboratory makes this determination on the basis of full susceptibility results from the MicroScan and supplemental testing if necessary. The chief intent is infection control. All patients infected with an isolate reported as an MDRO are put into contact precautions. We continue to use pre-2009 CLSI breakpoints for cephalosporins and carbapenems with supplemental testing for beta-lactamases as necessary. We generally do not do surveillance cultures to detect colonization, with the exception of weekly MRSA cultures in the NICU.

38 Our MDRO Definitions MRSA – by oxacillin or cefoxitin MIC or by growth on chromogenic medium VRE – by vancomycin MIC; E. faecalis and E. faecium only E. coli, Klebsiella, and Proteus mirabilis that produces ESBL enzymes Certain Enterobacteriaceae that produce plasmid-encoded AmpC enzymes

39 Our MDRO Definitions

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43 What about other bugs?

44 Is this an MDRO? Amox/ClavRLinezolidS CeftriaxoneROxacillinR ClindamycinSRifampinS CefazolinRTrim/SulfaS DaptomycinSTetracyclineS ErythromycinSVancomycinS GentamicinS LevofloxacinS GBGX:CDC:

45 Is this an MDRO? Amox/ClavSLinezolidS CeftriaxoneSOxacillinS ClindamycinRRifampinS CefazolinSTrim/SulfaS DaptomycinSTetracyclineR ErythromycinRVancomycinS GentamicinS LevofloxacinR GBGX:CDC:

46 Is this an MDRO? AmpicillinRLinezolidR DaptomycinSPenicillinR NitrofurantoinITetracyclineR Gent. SynergySVancomycinS LevofloxacinR GBGX:CDC:

47 Is this an MDRO? AmpicillinSLinezolidS DaptomycinSSynercidS NitrofurantoinSTetracyclineS Gent. SynergySVancomycinR LevofloxacinS GBGX:CDC:

48 Is this an MDRO? AmikacinRGentamicinR Amp/SulbactamILevofloxacinR CeftazidimeRMeropenemR CefotaximeRTetracyclineR CiprofloxacinRTrim/SulfaR CefepimeRTigecyclineR ColistinSTobramycinR GBGX:CDC:

49 Is this an MDRO? AmikacinSGentamicinS Amp/SulbactamSLevofloxacinR CeftriaxoneIMeropenemR CeftazidimeSTetracyclineR CefotaximeITrim/SulfaR CiprofloxacinRTobramycinS CefepimeS GBGX:CDC:

50 Is this an MDRO? AmikacinRImipenemS AztreonamRLevofloxacinS CeftriaxoneRMeropenemS CeftazidimeRPip/TazoR CefotaximeRPiperacillinR CiprofloxacinSTrim/SulfaR CefepimeRTetracyclineS GentamicinRTobramycinR GBGX:CDC:

51 Is this an MDRO? AmikacinSImipenemS AztreonamRLevofloxacinR CeftazidimeSMeropenemS CiprofloxacinRPip/TazoS CefepimeSPiperacillinS GentamicinITobramcyinS GBGX:CDC:

52 Is this an MDRO? Amp/SulbactamSErtapenemS AmikacinSImipenemS AmpicillinR*LevofloxacinS CeftriaxoneR*MeropenemS CeftazidimeR*Pip/TazoS CefazolinR*Trim/SulfaS CiprofloxacinSTetracyclineS CefepimeR*TobramycinS GBGX:CDC: Old breakpoints ESBL positive

53 Is this an MDRO? Amp/SulbactamRErtapenemS AmikacinSImipenemS AmpicillinRLevofloxacinS CeftriaxoneSMeropenemS CeftazidimeSPip/TazoS CefazolinRTrim/SulfaS CiprofloxacinSTetracyclineS CefepimeSTobramycinS GBGX:CDC:

54 Is this a CRE? Amp/SulbactamRCefazolinR AmpicillinRCefepimeS Amox/ClavRCefuroximeR AztreonamRErtapenemR CeftriaxoneRImipenemI CeftazidimeRMeropenemS CefotaximeRPiperacillinR CefoxitinRPip/TazoI CDC:CRE Toolkit:

55 Is this a CRE? Amp/SulbactamRCefazolinR AmpicillinRCefepimeS Amox/ClavRCefuroximeR AztreonamRErtapenemR CeftriaxoneRImipenemI CeftazidimeRMeropenemS CefotaximeRPiperacillinR CefoxitinRPip/TazoI CDC:CRE Toolkit: New breakpoints

56 Is this a CRE? Amp/SulbactamRCefazolinR AmpicillinRCefepimeS Amox/ClavRCefuroximeR AztreonamSErtapenemS CeftriaxoneSImipenemI CeftazidimeSMeropenemS CefotaximeSPiperacillinR CefoxitinRPip/TazoS CDC:CRE Toolkit: New breakpoints

57 Is this a CRE? Amp/SulbactamRCefazolinR AmpicillinRCefepimeS Amox/ClavRCefuroximeR AztreonamRErtapenemI CeftriaxoneRImipenemS CeftazidimeRMeropenemS CefotaximeRPiperacillinR CefoxitinRPip/TazoI CDC:CRE Toolkit:

58 So what to do? Will the lab designate isolates as MDRO? Why? What’s your purpose? How will the data be shared? Create meaningful definitions that fit your purpose. Continue to follow good selective reporting, but include non-reported drugs in determining MDRO status. Make determination of MDRO status as easy as possible. Automate if possible.

59 And thanks to Siemens for their sponsorship of this program.


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