1. Chapter 1: Introduction to Multidrug – Resistant Organisms
Texas department of state health services
Infectious disease control unit
Stephanie Titus, MPH
June 2014
Slide 1:
Welcome to Chapter One, an introduction to multidrug-resistant organisms. My name is Stephanie Titus.

2. Outline What are Multidrug – Resistant Organisms (mdros)?
What is the importance of mdros IN PUBLIC HEALTH?
Which mdros are reportable in texas?
How to report each mdro?
Slide 2:
The outline of this webinar is as follows:
What are multidrug-resistant organisms, or MDROs?
What is the importance of MDROs with reference to public health?
Which MDROs are currently reportable in Texas? And
How to report each MDRO.

3. What are Multidrug – Resistant Organisms?
Term used to describe bacteria that have acquired resistance to multiple antibiotic therapies or classes of antibiotics
Found in many healthcare settings:
Acute care facilities
Long-term care facilities
ICUs, NICUs
Burn units
Slide 3:
First, let’s discuss what multidrug-resistant organisms are. This is a term we use to describe bacteria that have acquired resistance to multiple antibiotic therapies or classes of antibiotics.
These MDROs can be found in many healthcare settings such as acute care facilities, long-term care facilities, ICUs, NICUs, and burn units.
The emergence of MDROs has been attributed to high levels of antibiotic usage, which is common in each of these health care settings. It further emphasizes the importance of antibiotic stewardship.

4. Who is at an increased risk of infection?
Immunocompromised
Chemotherapy
Transplant recipients
Individuals with chronic disease
HIV
Diabetes
Burn patients
Infants
Elderly
Slide 4:
The individuals who have the highest risk of infection are the immunocompromised, such as those undergoing chemotherapy and transplant recipients, individuals with chronic diseases such as HIV and diabetes, burn patients, infants and the elderly.
A weakened immune system makes the patient less able to fight off the infection.

5. Public Health Importance of MDRO Infections
Inappropriate treatment of MDRO may extend duration of illness
Alternative treatment options may be less effective, more expensive, or more toxic
MDRO infections are associated with longer hospital stays, increased morbidity and mortality
MDROs can move from the healthcare setting into the community
Slide 5:
Appropriate treatment and reporting of MDRO infections is very important to the public health of Texas. If a patient is inappropriately treated for an MDRO, it may extend the duration of the illness.
Also, because alternative drug therapies must be used to treat MDRO infections, these treatments may be less effective, more expensive, or potentially more toxic to the patient.
It has been shown that MDRO infections are associated with longer hospital stays, increased morbidity and increased mortality when compared to non-MDRO infections.
Finally, MDROs may move from the healthcare setting out into the community where they are harder to track, harder to treat, and ultimately harder to contain.

6. Reporting MDROs in Texas
Which MDROs must be reported
How to report mdros
Forms required for reporting
Slide 6:
Now we are going to talk about the reporting process for MDROs in Texas.
First, we will list the MDROs that must be reported.
Then, we’ll cover how to report each MDRO and the forms required for reporting them.

7. Which MDROs are immediately reportable in Texas?
Carbapenem resistant Enterobactericeae (CRE)
Limited to E. coli and Klebsiella spp.
Multidrug-resistant Acinetobacter (MDR-A)
Vancomycin-intermediate Staphylococcus aureus (VISA) and Vancomycin-resistant Staphylococcus aureus (VRSA)
Slide 7:
There are currently three MDROs that are immediately reportable in Texas:
Carbapenem resistant Enterobactericeae, or CRE. This is limited to E. coli and all Klebsiella species.
Multidrug-resistant Acinetobacter, or MDR-A. And,
Vancomycin-intermediate Staphylococcus aureus (also known as VISA) and vancomycin-resistant Staphylococcus aureus (also known as VRSA).

8. Carbapenem – Resistant Enterobactericeae (CRE)
Step 1: Identify a confirmed or suspected CRE isolate
Step 2: Notify local or regional health department
Step 3: If applicable, submit an isolate to dshs laboratory for confirmation
Slide 8:
We will start with a discussion of CRE.
The first step is to identify a CRE isolate.
The second step is to notify your local or regional health department.
The final step is to submit an isolate to the DSHS laboratory, but only if you have been indicated to do so by your health department.

9. Step 1: Identification of CRE
According to the Texas Administrative Code (TAC) and NHSN, CRE includes any Klebsiella species or E. coli that meets one or more of the following criteria:
Nonsusceptible (intermediate or resistant) to doripenem, meropenem, or imipenem
Positive phenotype test for carbapenemase (Modified Hodge Test)
Positive gene sequence test for carbapenemase (PCR test)
Slide 9:
The first step is identification of your CRE isolate.
According to the Texas Administrative Code, which is based on the National Healthcare Safety Network (or NHSN) standards, CRE includes any Klebsiella species or E. coli that meets one or more of the following criteria:
Nonsusceptible (either intermediate or resistant) to doripenem, meropenem, or imipenem.
Has a positive phenotype test for carbapenemase. This can be determined using a Modified Hodge Test.
Or has a positive gene sequence test for carbapenemase. This can be determined by doing a PCR Test.
Below you will see the 2012 Clinical Laboratory Standards Institute breakpoints that have been established for determining the level of resistance of a CRE isolate. These breakpoints are the most recently established guidelines.
2012 CLSI
Breakpoints
For CRE
Antibiotic
Susceptible
Intermediate
Resistant
Doripenem
≤1 μg/mL
2 μg/mL
≥4 μg/mL
Imipenem
Meropenem
(TAC Title 25, Part 1, Chapter 97, Subchapter A, Rules §97.3, 97.4, 97.7)

10. Step 2: Notify local or regional health department
Notify your local or regional health department immediately by phone.
Provide an Initial Provider Disease Report Form (EPI – 2 form) and supporting documents (H&P, discharge summary) to your local/regional health department. The MDRO form may also be required.
Initial Provider Disease Report Form found here
Multidrug Resistant Organism Investigation Form found here
Provide a copy of the lab report including:
List carbapenems tested
Susceptibilities to antibiotics
List minimum inhibitory concentrations (MICs) if available
Describe positive phenotype or PCR test (if applicable)
Slide 10:
The second step is notifying your local or regional health department.
First, you should immediately call your health department and tell them you have identified a CRE isolate.
Next, you should complete an Initial Provider Disease Report Form, also known as an EPI-2 form, and send it to the health department, along with additional  documentation, such as a copy of their history and physical or discharge summary.
Please also include a copy of the lab report, including the list of carbapenems tested, the susceptibilities to antibiotics, and the MICs if available. Also, please provide any positive phenotype or PCR test, if one was done.
The health department may also request an MDRO form be filled out.
The link to both the EPI-2 form and MDRO form is given.

11. Step 3: Submitting CRE Isolate to DSHS Laboratory
If directed by your health department, submit an isolate to the DSHS laboratory for confirmatory testing
Complete G2-B form with your submitter number
Provide a copy of lab report including
Antibiogram
MICs obtained
Source and date of culture
Send specimen in accordance with Category B Shipping Guidelines
For more information, see link to “Chapter 2: Reporting and Submitting CRE in Texas” on the original navigation page.
Slide 11:
The third step is submission of an isolate, if you have been told to do so by your health department.
Isolates are generally requested in the event of an outbreak, an unusual group expression of the disease, or during an investigation.
When submitting an isolate, you must include a G2-B form and a copy of the lab report, including the antibiogram, MICs, source and date of culture.
It is important to send the specimen in accordance with Category B Shipping Guidelines. For more information on this, please click on the link provided.
If you would like more information on reporting and submitting CRE in Texas, please click the link to Chapter 2 on the original navigation page.

12. Multidrug – Resistant Acinetobacter (MDR-A)
Step 1: Identify confirmed or suspected mdr-a isolate
Step 2: notify local or regional health department
Step 3: If applicable, submit an isolate to dshs laboratory for confirmation
Slide 12:
The next MDRO we will discuss is MDR-A.
The first step is to identify the confirmed or suspected MDR-A isolate.
The second step is to notify your local or regional health department.
The final step is to submit an isolate to the DSHS laboratory, but only if you have been indicated to do so by your health department.

13. Step 1: Notification of MDR-A
According to the TAC and NHSN, to qualify, the Acinetobacter isolate must be nonsusceptible to at least three of the following six antimicrobial classes:
Beta-lactam / beta-lactamase inhibitor combination
Amino-glycosides
Carbapenems
Fluoroquinolones
Cephalosporins
Sulbactam
Slide 13:
Again, the first step is identification.
According to the Texas Administrative Code and NHSN, an MDR-A is defined as an Acinetobacter that is nonsusceptible to a representative of at least three of the six antimicrobial classes listed below.
(TAC Title 25, Part 1, Chapter 97, Subchapter A, Rules §97.3, 97.4, 97.7)

14. Step 2: Notify local or regional health department
Notify your local or regional health department immediately by phone.
Provide an Initial Provider Disease Report Form (EPI – 2 form) and supporting documents (H&P, discharge summary) to your local/regional health department. The MDRO form may also be required.
Initial Provider Disease Report Form found here
Multidrug Resistant Organism Investigation Form found here
Include a copy of the lab report
Antibiogram
Describe susceptibilities to antibiotics tested
List minimum inhibitory concentration (MIC)
Slide 14:
The second step is notifying your local or regional health department.
You must notify your health department immediately by phone.
In addition, you must send an Initial Provider Disease Report Form, also known as an EPI-2 form, to the health department along with any additional documentation, such as a copy of their history and physical or discharge summary.
The health department may also request an MDRO form be filled out.
The link to both of these forms is given below.
When submitting these forms, please also include a copy of the lab report with the antibiogram, the susceptibilities to the antibiotics tested and the MICs if available.

15. Step 3: Submitting MDR-A Isolate to DSHS Laboratory
Finally, if directed by your health department, submit an isolate to the DSHS laboratory for confirmatory testing
Complete G2-B form with your submitter number
Provide a copy of lab report including
Antibiogram
MICs obtained
Source and date of culture
Send specimen in accordance with Category B Shipping Guidelines
For more information, see link to “Chapter 3: Reporting and Submitting MDR-A in Texas” on the original navigation page.
Slide 15:
The third step, if necessary and indicated by your health department, is to submit an isolate to the DSHS laboratory for confirmatory testing.
When submitting an isolate, you must also include a G2-B form and a copy of the lab report, including the antibiogram, MICs obtained, and the source and date of the culture.
As before, you must send the specimens in accordance with Category B Shipping Guidelines.
For more information on reporting and submitting MDR-A in Texas, please click the link to Chapter 3 on the original navigation page.

16. Vancomycin-Intermediate and Vancomycin-Resistant Staphylococcus aureus (VISA/VRSA)
Step 1: Identify confirmed or suspected visa/vrsa isolate
Step 2: notify local or regional health department
Step 3: submit an isolate to dshs laboratory for confirmation
Slide 16:
The last MDRO we will discuss is Vancomycin-Intermediate and Vancomycin-Resistant Staphylococcus aureus, also known as VISA and VRSA.
The first step is to identify your VISA/VRSA isolate.
The second step is to notify your local or regional health department.
The final step is to submit an isolate to the DSHS laboratory for testing. As opposed to CRE and MDR-A, you are always required to submit a VISA/VRSA isolate to the DSHS laboratory.

17. Step 1: Identification of VISA/VRSA
Vancomycin-intermediate S. aureus (VISA)
Defined as an MIC 4-8 μg/ml by CDC
Vancomycin-resistant S. aureus (VRSA)
Defined as an MIC >16 μg/ml by CDC
Texas Administrative Code requires any S. aureus isolate with MIC >2 μg/ml be submitted. DSHS has chosen a more inclusive case definition for surveillance purposes.
Slide 17:
As before, the first step is identification.
According to the CDC, VISA is defined by an MIC between 4 and 8 and VRSA is defined by an MIC greater than 16.
Currently, the Texas Administrative Code requires that any Staphylococcus aureus isolate with an MIC greater than 2 be submitted to the DSHS laboratory.
We have chosen a more inclusive case definition for surveillance purposes.
(TAC Title 25, Part 1, Chapter 97, Subchapter A, Rule §97.3)

18. Step 2: Notify local or regional health department
Notify your local or regional health department immediately by phone
Practitioners must complete two forms and submit them to your health department
1. VISA/VRSA Case Report Form
Form is found at the bottom of linked webpage
2. Initial Provider Disease Reporting Form (EPI-2)
Include a copy of the lab report
Describe susceptibility to vancomycin
List minimum inhibitory concentration (MIC)
Slide 18:
The second step is notifying the local or regional health department of your VISA/VRSA isolate.
Any confirmed or suspected VISA/VRSA isolate should be reported immediately by phone to your local or regional health department.
In addition, there are two forms you should send to your health department.
The first is the VISA/VRSA Case Report Form, and the second is the Initial Provider Disease Report Form, also known as the EPI-2 form.
Both of these forms can be found by following the links below.
When submitting these forms, please include a copy of the lab report describing the susceptibility to vancomycin and the MIC.

19. Step 3: Submitting a VISA/VRSA Isolate to DSHS Laboratory
Finally, you must submit a lab isolate to the DSHS laboratory for confirmatory testing
Complete G2-B form with your submitter number
Provide a copy of lab report including
Antibiogram
MICs obtained
Source and date of culture
Send specimen in accordance with Category B Shipping Guidelines
For more information, see link to “Chapter 4: Reporting and Submitting VISA/VRSA in Texas” on the original navigation page.
Slide 19:
The final step is to submit your VISA/VRSA isolate to the DSHS laboratory for confirmatory testing. Again, as compared to CRE and MDR-A, you are required to submit a VISA/VRSA isolate if the MIC is greater than 2.
You must include a G2-B form and a copy of your lab report with the specimen.
As always, please submit the specimen in accordance with category B shipping guidelines.
For more information on reporting and submitting VISA/VRSA in Texas, please see the link to Chapter 4 on the original navigation page.

20. Summary
MDROs are organisms that do not respond to multiple antibiotic therapies. They pose an formidable threat to public health in Texas.
CRE, MDR-A, and VISA/VRSA are the immediately reportable MDRO conditions in Texas.
Practitioners should notify their local or regional health departments and submit an isolate to the DSHS Laboratory as indicated.
Slide 20:
In summary, MDROs are organisms that do not respond to multiple antibiotic therapies. This quality makes MDROs a considerable threat to the public health of Texas.
The three MDROs which are immediately reportable in Texas are CRE, MDR-A and VISA/VRSA.
If you have a patient with one of these three infections, you must notify your local or regional health department, and, if indicated, submit the isolate to the DSHS laboratory.
Thank you for your attention. For more information, please see the additional chapters available on the original navigation page.