1. Time To Regain Control Management of Multi-Drug Resistant Organisms in Healthcare Settings fiuca@deaconess-cinti.comfiuca@deaconess-cinti.com513/559-2897

2. November 2006 – long awaited CDC guidelines released… Management of Multi-Drug Resistant Organisms in Healthcare Settings Background Epidemiology Prevention & Control Discussion Recommendations http://www.cdc.gov/ncidod/dhqp/pdf /ar/mdroGuideline2006.pdf

3. II. Background Definition: microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents MRSA/VISA/VRSA VRE MDR Strep pneumo ESBLs (E. coli, Kleb) Problem MDR gnrs Clinical Importance? – limited options for treating patients

4. III. Epidemiology Trend - ↑, Why? Selective pressure from antimicrobials CAMRSA Poor infection control practices Or any combination Transmission & Persistence – Naïve populations Antimicrobial use Increased potential due to ↑ #s infected/colonized Implementation/ adherence to prevention efforts

5. III. Epidemiology cont. MDROs are carried from one to another via “dirty ten” Easily contaminated from patient or environment Diarrhea patients an issue for those organisms colonizing the GI tract Not just for acute care setting Colonized HCP – Can become persistently colonized Limited role in transmission, unless… Chronic sinusitis URTI Dermatitis Etc

6. IV. Prevention and Control Appropriate clinical practices as a part of ALL routine patient care, ie., Hand hygiene – “When in doubt, wash ‘em out” Prompt/accurate diagnosis Vent bundles Central Line bundles SSI bundles Urinary Catheters Judicious antimicrobial selection & utilization, DUEs Utilization of PPE

7. Control Interventions Administrative Support Education Judicious Antimicrobial Use Surveillance Infection Control Precautions Environmental Measures Decolonization

8. V. Discussion - Issues Impact on other MDROs Costs Feasibility Type & significance of institutional problem Population & healthcare setting Differences in opinion on strategies Two-tiered approach

9. Recommendations: Tier 1 Administrative Measures: Patient safety priority Fiscal & human resources Expertise Communication systems Multidisciplinary process ID of patients infected or colonized Community participation Timely feedback, minimum annually

10. Recommendations: Tier 1 Education & Training… Risks & prevention of transmission Orientation Periodic updates Include organizational experiences & strategies Judicious Use of Antimicrobials Multidisciplinary process for use, formulary selection & antibiogram…for hospitals & LTCF Physician prompts – all healthcare settings Antibiogram – available for all in facility

11. Recommendations: Tier 1 Surveillance Standardized methods in micro lab Notification from lab Storage for MDROs… hospitals & LTCF Facility susceptibility reports Hospitals/LTCF – special unit reports Annual & include in lab contract Monitor trends – house-wide & unit specific rates using statistical methods Use this to determine interventions Establish a baseline or incidence Evaluate colonization versus infection Reporting frequency

12. Recommendations: Tier 1 Precautions: Standard precautions Masks – appropriate use Contact precautions Acute care: infected or colonized; can modify LTCF: evaluate pt & situation for infected or colonized; modify If ill, use Contact

13. Recommendations: Tier 1 Precautions cont: Ambulatory Care: standard precautions with strict adherence to barrier use Home Care: standard precautions with strict adherence to barrier use Limit use of reusable equipment Appropriate disinfection if can’t leave it Hemodialysis: “Recommendations to Prevent Transmission of Infections in Chronic Hemodialysis Patients” www.cms.hhs.gov/home/regsguidance.asp

14. Recommendations: Tier 1 Discontinuation of precautions: No recommendation for when! Placement - hospitals & LTCF Private room – prioritize when limited availability Cohort same MDRO only If not possible, place with those at low risk of acquisition & adverse outcome

15. Recommendations: Tier 1 Environmental Measures: Frequently touched surfaces & equipment cleaned/disinfected Dedicate non-critical medical items Prioritize Contact Precautions rooms

16. Recommendations: Tier 2 Intensified Interventions Utilize in various combinations When? If incidence/prevalence not ↓ 1 st case or outbreak of important MDRO Continue to monitor Add interventions as needed

17. Recommendations: Tier 2 Adminstrative Expertise – design, implementation, evaluation Leadership, funding, daily oversight Evaluate health system factors → action plan Detailed updates Educational Interventions Increase frequency – unit-specific feedback Judicious Use of Antimicrobials Review & control use as indicated

18. Recommendations: Tier 2 Surveillance Calculate & Analyze prevalence & incidence rates for infected & colonized Do not use multiple isolates from same patient Active Surveillance Cultures (ASC) – develop & implement protocols Include areas of skin breakdown & draining wounds including organism specific colonization sites At admission & as needed to assess

19. Recommendations: Tier 2 Surveillance cont. Conduct serial unit- specific point prevalence surveys to assess progress Repeat point prevalence cultures at discharge or transfer or other interval Test roommates Test HCP if implicated

20. Recommendations: Tier 2 Enhanced Infection Control Precautions: Implement contact precautions until results of ASC are known Assign dedicated nursing & ancillary personnel Consider stopping new admissions Enhanced Environmental Measures: Intensify & reinforce training Monitor adherence to cleaning policies Environmental cultures, if necessary Vacate units for thorough cleaning

21. Recommendations: Tier 2 Decolonization: Usually only for MRSA Consult with experts on case-by-case basis If utilize, perform susceptibility testing Do not use topical mupirocin routinely as resistant strains emerge Only decolonize HCP implicated in ongoing transmission Possibly reassign personnel

22. Thank You…Questions?