1. Preventing Multidrug-Resistant Organisms (MDROs) What the Direct Caregiver Should Know Prepared by: Ann Bailey, RNC, BSN, CIC Joanne Dixon, RN, MN, CIC December 17, 2009

2. Objectives: Upon completion of this module, the learner will: Define Multidrug Resistant Organisms (MDRO) Name 2 MDROs State the type of precautions to be used with all patients and under what circumstances you would wear gloves Name the type of isolation in which to place someone with an MDRO

3. What are Multi-Drug Resistant Organisms? (MDROs) MDROs are microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents Examples of MDROs (not all inclusive) Methicillin-resistant staphylococcus aureus (MRSA) Vancomycin-intermediate staphylococcus aureus (VISA) Vancomycin-resistant staphylococus aureus (VRSA) Vancomycin-resistant enterococcus (VRE) Streptococcus pneumoniae resistant to penicillin and other broad-spectrum agents

4. What are Multi-Drug Resistant Organisms? (MDROs) Other Examples of MDROs Some gram-negative organisms with strains that have developed the ability to produce ESBL (extended- spectrum beta-lactamase) which is an enzyme that inactivates beta-lactam antibiotics such as the penicillins and cephalasporins Klebsiella pneumonia Escherichia coli (E. Coli) Acinetobacter baumannii Stenotrophomonas maltophilia

5. Why Concern over MDRO Infections? Cause serious, difficult-to-treat infections that can result in substantial morbidity, mortality, increased lengths of stay and excess cost Frequently preventable – Usually acquired via transmission by: caregiver-to-patient, environment-to-patient, or patient-to- patient Judicious use of antimicrobials may decrease incidence of microorganisms developing antibiotic resistance

6. What Measures Can We Take to Prevent Transmission of MDROs? Hand Hygiene – The Most Important Way to Prevent Transmission of Microorganisms and Infection

7. What Other Measures Can We Take to Prevent Transmission of MDROs? Isolation Precautions Follow Standard Precautions during all patient encounters in all settings in which healthcare is delivered. Remember Standard Precautions is using appropriate personal protection equipment (PPE) to protect against exposure to body fluids Gloves, gown, mask and eye protection according to assessed risk of exposure

8. What Other Measures Can We Take to Prevent Transmission of MDROs? Isolation Precautions Develop and utilize systems to identify patients with MDROs and notify Infection Preventionists, physicians and direct caregivers Place patients with a confirmed MDRO or history of an MDRO in single-patient rooms. Group patients with the same MDRO in designated areas if single-patient room unavailable

9. What Other Measures Can We Take to Prevent Transmission of MDROs? Isolation Precautions Implement Contact Precautions immediately for all patients infected with MDROs, that have a previously identified MDRO or have a history of being colonized with target MDROs (Implementation of isolation is a nursing order. It does not require a doctor’s order.) Notify Infection Prevention and Control after placing the patient in isolation

10. What Other Measures Can We Take to Prevent Transmission of MDROs? Contact Precautions Perform hand hygiene before donning personal protective equipment (PPE – gown, gloves, goggles, face shield) Gown and gloves worn upon entering room Use eye/face protection if risk of splatter/splash is anticipated (e.g., patient is coughing or sneezing or has trach) Discard PPE before leaving room Perform hand hygiene after discarding PPE

11. What Other Measures Can We Take to Prevent Transmission of MDROs? Isolation Precautions For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas Consult Infection Prevention & Control prior to discontinuing isolation on a patient even if a physician has written an order for such

12. What Measures Can We Take to Prevent Transmission of MDROs? Environmental Measures Clean and disinfect high-touch surfaces (eg bedrails, faucet handles) and equipment used in the patient’s environment that may be contaminated with pathogens Dedicate noncritical medical items for use on patients known to be infected or colonized with an MDRO Infected: organisms present, tissue invasion and symptoms are present Colonized: organisms present but no tissue invasion and patient is asymptomatic

13. What Other Measures are Seton Family of Hospitals Taking to Prevent Development of MDROs? Judicious use of Antimicrobial agents Monitoring appropriate use of antimicrobial agents Periodic development and distribution of antibiograms Educating clinicians regarding appropriate prescribing of antimicrobial agents

14. In Summary – Prevention of MDROs Hand Hygiene, Hand Hygiene, Hand Hygiene Isolation Precautions Standard Precautions for all patients Contact Precautions for patients identified as having an MDRO Environmental Measures Judicious use of Antimicrobial agents

15. Your Role Follow the above recommended practices and measures specific to your role in the patient’s care Provide appropriate/indicated patient teaching regarding these recommended practices Document patient education related to the goal of prevention of MDROs Patient education materials related to infection prevention can be found on the Intranet: http://intranet.seton.org/polandproc/infectcontrol/fact_and_e ducation_sheets/index.phphttp://intranet.seton.org/polandproc/infectcontrol/fact_and_e ducation_sheets/index.php Remind peers of the importance of following the recommended practices if they are observed to be non- compliant

16. Questions? Contact the Infection Preventionist at your site

17. References http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroG uideline2006.pdfhttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroG uideline2006.pdf