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

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Presentation on theme: "Multidrug-Resistant Nosocomial Infections in the PICU : how to deal with it? Somchai Suntornlohanakul."— Presentation transcript:

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

3 Scope of Presentation Introduction & Background of MDROIntroduction & Background of MDRO Epidemiology of MDROEpidemiology of MDRO MDRO prevention and controlMDRO prevention and control Preventing nosocomial infection in PICU: practical point for NursePreventing nosocomial infection in PICU: practical point for Nurse

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

5 The administration of healthcare organizations and institutions should ensure thatThe 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 The prevention and control of MDRO is a national priority

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

7 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 transmissionInfection 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

8 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 Although the names of certain MDRO describe resistance to only one agent (e.g., MRSA, VRE, [ESBL]-producing or only one agent (e.g., MRSA, VRE, [ESBL]-producing or intrinsically resistant Gram-negative bacilli), these pathogens intrinsically resistant Gram-negative bacilli), these pathogens are frequently resistant to most available antimicrobial agents are frequently resistant to most available antimicrobial agents

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

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

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

12 Prevalence of target MDRO in the adult patient is greater than pediatric population.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: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 effortsMDRO burden is greatest in adult hospital patients, but require similar control efforts Epidemiology of MDRO

13 Important concepts in transmission Transmission and persistence of the resistant strain is determined byTransmission 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

14 Ample epidemiologic evidences suggest that MDRO are carried from one person to another via the hands of HCPAmple 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 patientsWithout 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 programsStrategies to increase and monitor adherence are important components of MDRO control programs Important concepts in transmission

15 Role of colonized HCP in MDRO transmission Rarely, HCP may introduce an MDRO into a patient care unitRarely, 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.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 dermatitisFactors that can facilitate transmission, include chronic sinusitis, upper respiratory infection, and dermatitis

16 MDRO Prevention and Control

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

18 Prevention and Control of MDRO transmission Successful control of MDRO has been documented in theSuccessful control of MDRO has been documented in the US and abroad using a variety of combined interventions 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

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20 Control Interventions Administrative supportAdministrative support MDRO EducationMDRO Education Judicious Antimicrobial UseJudicious Antimicrobial Use MDRO SurveillanceMDRO Surveillance Infection Control Precautions to Prevent TransmissionInfection Control Precautions to Prevent Transmission Environmental MeasuresEnvironmental Measures DecolonizationDecolonization

21 Administrative Support Implementing system changes to ensure prompt and effective communicationsImplementing 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 facilityProviding 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 requiredMaintaining staffing levels appropriate to the intensity of care required

22 Enforcing adherence to recommended infection control practices for MDRO controlEnforcing adherence to recommended infection control practices for MDRO control Adherence monitoringAdherence monitoring Participation in regional or national coalitions to combat emerging or growing MDRO problemsParticipation in regional or national coalitions to combat emerging or growing MDRO problems Administrative Support

23 Control Interventions Administrative supportAdministrative support MDRO EducationMDRO Education Judicious Antimicrobial UseJudicious Antimicrobial Use MDRO SurveillanceMDRO Surveillance Infection Control Precautions to Prevent TransmissionInfection Control Precautions to Prevent Transmission Environmental MeasuresEnvironmental Measures DecolonizationDecolonization

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

25 Control Interventions Administrative supportAdministrative support MDRO EducationMDRO Education Judicious Antimicrobial UseJudicious Antimicrobial Use MDRO SurveillanceMDRO Surveillance Infection Control Precautions to Prevent TransmissionInfection Control Precautions to Prevent Transmission Environmental MeasuresEnvironmental Measures DecolonizationDecolonization

26 Pharmacokinetic (PK)/Pharmacodynamic (PD) considerations The goal of antibiotic therapy is to achieve complete bacterial eradication and to minimise the risk of resistance selectionThe 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 pathogenThe 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 intervalTo predict bacteriological and clinical efficacy and help to identify the correct dose and dosing interval

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

28 Strategies for influencing antimicrobial prescribing patterns EducationEducation Formulary restrictionFormulary restriction Prior-approval programsPrior-approval programs Automatic stop ordersAutomatic stop orders Academic interventions to counteract pharmaceutical influences on prescribing patternsAcademic interventions to counteract pharmaceutical influences on prescribing patterns Computer-assisted management programsComputer-assisted management programs Active efforts to remove redundant antimicrobial combinationsActive efforts to remove redundant antimicrobial combinations

29 Control Interventions Administrative supportAdministrative support MDRO EducationMDRO Education Judicious Antimicrobial UseJudicious Antimicrobial Use MDRO SurveillanceMDRO Surveillance Infection Control Precautions to Prevent TransmissionInfection Control Precautions to Prevent Transmission Environmental MeasuresEnvironmental Measures DecolonizationDecolonization

30 MDRO surveillance Surveillance is a critically important component of any MDRO control programSurveillance 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 strategiesMDRO surveillance strategies –surveillance of clinical microbiology laboratory results obtained as part of routine clinical care –active surveillance cultures (ASC) to detect asymptomatic colonization

31 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

32 1.1 Antibiograms 1.1 Antibiograms Monitoring of clinical microbiology isolates resulting from tests ordered as part of routine clinical careMonitoring of clinical microbiology isolates resulting from tests ordered as part of routine clinical care Detect emergence of new MDRODetect emergence of new MDRO Prepare facility- or unit-specific summary antimicrobial susceptibility reports that describe pathogen-specific prevalence of resistance among clinical isolatesPrepare 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 patternsUseful to monitor for changes in known resistance patterns Provide clinicians with information to guide antimicrobial prescribing practicesProvide clinicians with information to guide antimicrobial prescribing practices

33 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)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 programsUseful for monitoring MDRO trends and assessing the impact of prevention programs Based solely on positive culture results without accompanying clinical informationBased solely on positive culture results without accompanying clinical information

34 Do not distinguish colonization from infectionDo 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 unitCulture 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 culturesAcquire MDRO colonization may remain undetected by clinical cultures MDRO Incidence Based on Clinical Culture Results

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

36 1.3 MDRO Infection Rates Requires investigation of clinical circumstances surrounding a positive culture to distinguish colonization from infectionRequires 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 facilityCan be particularly helpful in defining the clinical impact of MDRO within a facility

37 1.4 Molecular typing of MDRO isolates Many investigators have used molecular typingMany investigators have used molecular typing of selected isolates to confirm clonal transmission of selected isolates to confirm clonal transmission to enhance understanding of MDRO transmission to enhance understanding of MDRO transmission and the effect of interventions within their facility and the effect of interventions within their facility

38 2. Surveillance for MDRO by Detecting Asymptomatic Colonization Active Surveillance Cultures (ASC) to identify patients who are colonized with a targeted MDROActive 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 careBased 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

39 Use of ASC incorporated into MDRO prevention programs Support for successful implementation includesSupport 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

40 Populations targeted for ASC Not well definedNot well defined High risk for MDRO colonization based onHigh 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 colonizationAll patients admitted to units experiencing MDRO colonization

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

42 Methods for obtaining ASC Must be carefully considered, and vary depending upon the MDRO of interestMust be carefully considered, and vary depending upon the MDRO of interest MRSA: cultures of the nares, peri-rectal and wound cultures can identify additional carriersMRSA: cultures of the nares, peri-rectal and wound cultures can identify additional carriers VRE: Stool, rectal, or peri-rectal swabsVRE: Stool, rectal, or peri-rectal swabs MDR-GNB: peri-rectal or rectal swabs alone or in combination with oro-pharyngeal, endotracheal, or wound culturesMDR-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 processThe 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

43 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.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.If empiric precautions are used pending negative surveillance culture results, precautions may be unnecessarily implemented.

44 Control Interventions Administrative supportAdministrative support MDRO EducationMDRO Education Judicious Antimicrobial UseJudicious Antimicrobial Use MDRO SurveillanceMDRO Surveillance Infection Control Precautions to Prevent TransmissionInfection Control Precautions to Prevent Transmission Environmental MeasuresEnvironmental Measures DecolonizationDecolonization

45 Infection Control Precautions Standard PrecautionsStandard Precautions Contact PrecautionsContact Precautions Cohorting and other MDRO control strategiesCohorting and other MDRO control strategies Duration of Contact PrecautionsDuration of Contact Precautions Impact of Contact Precautions on patient care and well-beingImpact of Contact Precautions on patient care and well-being

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

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

48 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 environmentHCP 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 doneDonning gown and gloves upon room entry and discarding before exiting the patient room is done

49 Cohorting and other MDRO control strategies Cohorting of patientsCohorting of patients Cohorting of staffCohorting of staff Use of designated beds or units, unit closure were necessary to control transmissionUse of designated beds or units, unit closure were necessary to control transmission

50 Duration of Contact Precautions Remains an unresolved issueRemains 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 patientsIn the context of an outbreak, prudence would dictate that Contact Precautions be used indefinitely for all previously infected and known colonized patients

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

52 In general, discontinue contact precautions whenIn 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 Duration of Contact Precautions

53 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 precautionsHCP, attending physicians, were half as likely to enter the rooms of or examine patients on contact precautions Had significantly more preventable adverse eventsHad significantly more preventable adverse events Increased anxiety and depression scoresIncreased anxiety and depression scores Expressed greater dissatisfaction with their RxExpressed greater dissatisfaction with their Rx Efforts must be made by the healthcare team to counteract these potential adverse effectsEfforts must be made by the healthcare team to counteract these potential adverse effects

54 Control Interventions Administrative supportAdministrative support MDRO EducationMDRO Education Judicious Antimicrobial UseJudicious Antimicrobial Use MDRO SurveillanceMDRO Surveillance Infection Control Precautions to Prevent TransmissionInfection Control Precautions to Prevent Transmission Environmental MeasuresEnvironmental Measures DecolonizationDecolonization

55 x x x x x x x x Contaminated surfaces increase cross-transmission x

56 Control Interventions Administrative supportAdministrative support MDRO EducationMDRO Education Judicious Antimicrobial UseJudicious Antimicrobial Use MDRO SurveillanceMDRO Surveillance Infection Control Precautions to Prevent TransmissionInfection Control Precautions to Prevent Transmission Environmental MeasuresEnvironmental Measures DecolonizationDecolonization

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

58 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 Decolonization

59 Other Questions Impact on other MDRO from interventions targeted to one MDROImpact on other MDRO from interventions targeted to one MDRO CostsCosts FeasibilityFeasibility Factors that influence selection of MDRO control measuresFactors that influence selection of MDRO control measures Differences of opinion on the optimal strategy to control MDRODifferences of opinion on the optimal strategy to control MDRO

60 Factors that influence selection of MDRO control measures No single approach to the control of MDRO is appropriate for all healthcare facilitiesNo 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, includingFactors 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

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

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


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