January

1. MDRO (Multiple drug-resistant organisms) How they relate to patients in the healthcare setting UT Southwestern University Hospitals: Infection Control Department

2. Multi-drug resistant organisms (MDRO’s) have increased in prevalence in US hospitals over the last three decades These organisms have important implications for patient safety Options for treating patients with these infections are often extremely limited MDRO infections are associated with increased lengths of stay, costs, and mortality Background

3. Methicillin Resistant Staphylococcus aureus (MRSA) was first isolated in the United States in 1968. In the early 1990s, MRSA accounted for 20%-25% of Staphylococcus aureus isolates from hospitalized patients. By 2003, MRSA accounted for >50% of S. aureus isolates from patients in ICUs. A similar rise in prevalence has occurred with Vancomycin Resistant Enterococcus (VRE) . From 1990 to 1997, the prevalence of VRE in Enterococcus isolates from hospitalized patients increased from <1% to approximately 15% . By 2003 VRE accounted for 28.5 % of Enterococcus isolates in ICUs. History of MDRO’s

4. Methicillin-Resistant Staphylococcus aureus (MRSA) Vancomycin-Resistant Enterococcus species (VRE) Multidrug-Resistant (MDR) Acinetobacter species. Multidrug-Resistant (MDR) Klebsiella species, Enterobacter species, and Escherichia coli. Resistant Organisms include:

5. To be defined as an MDRO the organism must meet these criteria: MRSA: S. aureus tests resistant to Oxacillin VRE: Enterococcus species tests resistant to Vancomycin. MDRO-Acinetobacter species: Resistant to all agents tested within at least 3 antimicrobial classes, including B-lactams, carbapenems, aminoglycosides and fluoroquinolones Specific definitions

6. Resistant Bacteria Mutations XX Resistance Gene Transfer New Resistant Bacteria Emergence of Antimicrobial Resistance Susceptible Bacteria Bacteria have evolved to evade antimicrobial drugs through chromosomal mutations & acquisition of resistance genes via conjugation, transposition, or transformation

7. Resistant StrainsRare Antimicrobial Exposure x Resistant Strains Dominant x x x x x x x x x x x Selection for antimicrobial-resistant Strains Once resistant strains of bacteria are present in a population, exposure to antimicrobial drugs favors their survival.

8. Methicillin Methicillin-resistant S. aureus (MRSA) [1970s] Vancomycin [1997] [1990s] [ ???? ] Vancomycin-resistant Vancomycin Vancomycin- resistant S. aureus enterococci (VRE) intermediate- resistant S. aureus (VISA) Penicillin Penicillin-resistant S.aureus [1950s] S. aureus Introduction of every new class of antimicrobial drug is followed by emergence of resistance

9. B-lactams: includes ampicillin/sulbactam, piperacillin/tazobactam, cefepime, ceftazidime Carbapenems: includes imipenam, meropenem and doripenam Aminoglycosides: includes amikacin, gentamycin, tobramycin Fluoroquinolones: includes ciprofloxacin, levofloxacin Drug classes:

10. Staphylococcus aureus commonly found on skin, in eyes, upper respiratory track, mouth, and GU system developed resistance to many Antibiotics including Methicillin (oxacillin) to create the particular strain, MRSA MRSA Is found anywhere Staphylococcus aureus is commonly found may colonize the patient or cause active infections is a public health concern because there are few drugs left to treat serious MRSA infections. Vancomycin is the current drug of choice for serious infections. Other antimicrobial agents would include: Daptomycin and Linezolid. A high percentage of wound infections are caused by MRSA. Reservoirs for MRSA in the hospital include infected or colonized patients with HCW being the link for nosocomial spread of the infection. The main mode of transmission is via hands of HCW. Other reservoirs include contaminated equipment and other items in the environment Methicillin-Resistant Staphylococcus aureus (MRSA)Fact Sheet

11. The emergence of new epidemic strains of MRSA in the community, (CA-MRSA) among patients without established MRSA risk factors, may present new challenges to MRSA control in healthcare settings. Historically, genetic analyses of MRSA isolated from patients in hospitals worldwide revealed a relatively small number of MRSA strains have the unique qualities to facilitate transmission from patient to patient. To date, most MRSA strains isolated from patients with CA-MRSA infections have been microbiologically distinct from those endemic in healthcare settings, suggesting some of these strains may have arisen de novo in the community via the acquisition of the mecA gene from Methicillin Susceptible Staph aureus. CA-MRSA infection commonly presents as relatively minor skin and soft tissue infections, but severe invasive disease and mortalities have been described in children and adults. Community-associated MRSA

12. When a patient is identified as having an infection or colonization with an MDRO: Place the patient in Contact Precautions Enter the isolation information into EPIC Staff will be alerted of isolation status upon subsequent admissions into the hospital Monitoring of MDRO’s

13. Infection control monitors MDRO incidence and transmission and provides data monthly and quarterly to the units Monitoring of MDRO’s

14. Removing Patients From Isolation Follow-up screenings MUST be negative: Original site of infection + Nasal if previously MRSA positive or Rectal if previously VRE positive Once the C. Diff positive patient is discharged, the isolation is removed automatically Notify Infection Control to Remove Isolation Status from EPIC

15. Once MDROs are introduced into a healthcare setting, transmission and persistence of the resistant strain is determined by the: availability of vulnerable patients selective pressure exerted by antimicrobial use. the number of patients already colonized with an MDRO the impact of implementation and adherence to prevention efforts Patients vulnerable to colonization and infection include: those with severe disease those with compromised host defenses from underlying medical conditions recent surgery indwelling medical devices (e.g., urinary catheters or endotracheal tubes) Hospitalized patients have more risk factors than non-hospitalized patients, and have the highest infection rates.

16. Hands are the culprits There is ample epidemiologic evidence to suggest MDROs are carried from one person to another via the hands of HCW. Hands are easily contaminated during the process of care-giving or from contact with environmental surfaces in close proximity to the patient. Without adherence to published recommendations for hand hygiene and glove use HCW are more likely to transmit MDROs to patients. Strategies to increase and monitor adherence are important components of MDRO control programs.

17. Standard Precautions are a group of infection prevention practices which apply to all patients, regardless of suspected or confirmed infection status. They are in effect for all patients, all the time. These include the use of: * Hand hygiene Gloves Gown Mask Eye protection, or face shield *depending on the anticipated exposure; and safe injection practices. Equipment or items in the patient environment likely to have been contaminated with body fluids must be handled in a manner to prevent transmission of infectious agents.

18. While good hand hygiene remains the most important method to prevent the transmission of any organism on the hands of HCW, the addition of Contact Precautions can break the chain of infection by preventing the organisms from being carried from one room to another on inanimate objects (foamites). Contact Precautions

19. Touching the PATIENT isn’t the only way to become contaminated with an MDRO!

20. Contact Isolation Precautions Place green Contact Isolation sign on the room door Any PERSON entering the room wears gloves and gown, no matter the reason for entering the room or for how long. This includes all staff and visitors.

21. Contact Isolation Precautions Remove Personal Protective Equipment and perform hand hygiene BEFORE leaving the room. Equipment from a Contact Precautions room should be disinfected before being used for the care of another patient .

22. Contact Isolation Precautions Sign

23. Stop Sign for Clostridium difficile Contact Precautions + Use ONLY soap & water to wash hands

24. Droplet Isolation Precautions Sign

25. Airborne Isolation Precautions Sign

26. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

28. Use the correct catheter

29. Use proper insertion & catheter-care protocols

31. The Infection Control Team Doramarie Arocha David Townson Gwen Way

33. Treat bacteremia, not the catheter tip or hub

35. Know when to say “no” to vanco Fact: Vancomycin overuse promotes emergence, selection, and spread of resistant pathogens. Actions: Treat infection, not contaminants or colonization Fever in a patient with an intravenous catheter is not a routine indication for vancomycin

37. When cultures are negative and infection is unlikely

40. Prevent Transmission: Contain your contagion Patients from Long Term Acute Care Facilities (LTAC) have a higher incidence of being colonized with an MDRO Isolate immediately upon arrival, no questions asked! Follow MDRO Reduction Protocol Notify Infection Control

42. Dallas

43. Fort Worth

44. Plano

45. Vibra Specialty Hospital

46. Texas Specialty Hospital

47. Kindred Specialty Hospital

48. Multiple Locations in Dallas and Fort Worth

49. Arlington

50. Mansfield

51. Gulf States LTAC

52. Select Specialty

53. DeSoto

54. Carrolton

55. Mesquite Specialty Hospital

56. Regency Hospital

57. Carrolton

58. Fort Worth

59. Plano Specialty Hospital

60. Baylor Specialty HospitalMulti-Drug Resistant Organism Reduction (MDRO) Protocol: Known LTACs

61. Multi-Drug Resistant Organism (MDRO) Reduction Screening Protocol

64. Transport the labeled specimen to the lab WITHIN 1 HOUR.

65. Label the swab with the patient’s preprinted label in the presence of the patient, in the patient’s room

66. Remove and discard gloves

67. Place in biohazard bag

68. Transport the labeled specimen to the lab WITHIN 1 HOUR.Push the end of the swab firmly to ensure that the swab is inserted into the end of the transport tube. Ensure that the swab tip is in contact with the moistened pledget. Secure the transport tube cap. Label the swab with the patient’s preprinted label in the presence of the patient, in the patient’s room Remove and discard gloves

70. Contain your contagion

71. Keep your hands clean