1. Multi Drug ResistantMulti Drug Resistant
Organisms (MDROs) in HealthOrganisms (MDROs) in Health
Care setting :Care setting :
use of standardized metrics touse of standardized metrics to
monitor local prevention effortsmonitor local prevention efforts
Dr. Ashok Rattan,
Chief Executive,
Fortis Clinical Research Ltd.,
Adviser,
Religare SRL Diagnostics labs in
Fortis / Escorts Hospitals, Delhi & NCR

2. 100
80
60
40
20
0
19801975 1985 1990 1995 2000
1997
VISAVISA
VREVRE
PRSPPRSP
MRSAMRSA
MRSEMRSE
Percentage
of
Pathogens
Resistant to
Antibiotics
Increasing Incidence of Resistance in
the US
MRSE, MRSA, VRE, PRSP, GISA
1980-2006
VRSAVRSA
2006

3. Crisis of Pan Resistant Bacteria
• Pre existing or Acquisition of new
resistance by bacteria
Mutation
Spread within clone
Vertical
Horizontal
• Expansion of clone &
Dissemination of resistant bacteria
Biological PhenomenonBiological Phenomenon
Partly Mechanical PhenomenonPartly Mechanical Phenomenon

4. Antibiotic Stewardship Programme
• Effective antimicrobial
stewardship
– Audit & feedback
– Guidelines & algorithms
– Antibiotic order form
– Combination
– De escalation
– Dose optimization
– Parentral  oral
– Cycling
• Comprehensive Infection
control
– Managing data and
information
– Policies & procedures
– Regulatory requirements
– Employee health
– Prevent transmission,
investigate outbreaks
– Education & training
– Mobilize resources: human
& financial

5. Monitoring MDROs is important
• To
– Detect newly emerging antimicrobial profile
– Identify vulnerable patient population
– Assess need for & effectiveness of, intervention
• Why
– Incidence has increased in the past decades
– Options for treatment are limited
– Has important implications for patient safety
– Associated with prolonged stay, costs and mortality

6. Which MDROs should we monitor ?
Choice need to be facility based
• May include:
– MRSA & VRSA
– VRE
– MDR GNB
• Pseudomonas aeruginosa
• Acinetobacter baumannii
• Klebsiella pneumoniae
• Escherichia coli
• Before staring make sure clear cut definitions are in
place & understood by all participating in surveillance

7. MDROs Metrics
5 categories of outcome measures
1. Tracking patients
2. Monitoring susceptibility patterns
3. Estimating infection burden
4. Estimating Exposure burden
5. Quantifying healthcare acquisition
Preventive Process Measures
• Monitor adherence to Hand Hygiene
• Monitor adherence to Gown & Glove use
• Monitor adherence to Active Surveillance Testing

8. 1. Tracking patient
• A. Line listing:
– Not a rate, so no denominator,
– No defined period, continuously updated
– Essential elements of line listing:
» Pt identification,
» Hospital location
» Date of admission
» Date and time of sample collection
» Source of sample
» Date of first positive
– Useful to flag patients for
» identification and
» contract isolation

9. A. Line Listing
• Simple
• Could be the only essential metrics for rare MDROs
• For common MDROs like MRSA it provides
– Identification of patient
– History of infection or colonization
• Can trigger & follow outbreak investigation for new
or rapidly emerging MDROs
• Initial part of any risk assessment; identifies pts
with a prior history of colonization or infection. This
might be the only metrics necessary for rare
MDROs (eg VRSA)

10. 1. Tracking patient
A. Line Listing
• Type of microbiology data required:
– Clinical culture data (& AST data if available)
• Numerator
– Pt with newly recovered MDRO isolate (regardless of
specimen source) by HCF
• Denominator
– None
• Surveillance interval
– Continuous
• Location of use
– Whole HCF

11. 2. Monitoring susceptibility pattern
• A. Antibiogram:
• To provide guidance for antimicrobial prescription
• Monitor progress is assessing proportion of MDRO resistant to
certain antibiotics of interest
• CLSI Recommendations of Antibiogram:
1.Methods of summarizing susceptibility data
2.Report results in “percent susceptible”
3.Organisms morphological grouping
4.Duplicate isolate notification
5.Description of exact collection period.
6.Number of isolates for each organism.
7.Reporting only organisms with greater than 30 isolates.
8.Use of Generic names of antimicrobials.
9.Utilization of CLSI approved antimicrobial abbreviations.
10.Utilization of “dash” to describe susceptibility data not reported
11.Annual reporting of results

15. 2. Monitoring Susceptibility Pattern
A. Antibiogram
• Type of microbiology data required:
– Clinical culture data
• Numerator
– Number of first susceptible clinical isolates (regardless of
specimen source) per pt for each unit or HCF
• Denominator
– Total number of isolates (both S & R) per pt. for each unit or
HCF
• Surveillance interval
– Atleast annually
• Location of use
– Whole HCF (consider use for specific units or populations)

16. 3. Estimation of Infection Burden
A. Metrics:
Incidence or Incidence density rate of hospital onset
bacteremia
Basic for all MDROs, especially for emergence of new
resistance

17. 3. Estimation of Infection Burden
A. Incidence density rate of hospital onset bacteremia
• Type of microbiology data required
– Blood culture data only
• Numerator
– Number of MDRO isolates recovered from blood samples for
each unit or HCF > 3 calendar days after admission to unit or
HCF
• Denominator
– 100 pt admissions (incidence); 1000 pt days ( inc. density)
• Surveillance interval
– Monthly
• Location of use
– Specific units (consider use for whole HCF)

18. B. Metrics:
Nosocomial organism specific infection
incidence or incidence density
Useful for assessing burden of a specific
organism regardless of extrinsic risk factors (eg
catheter or ventilator use)
3. Estimation of Infection Burden

19. 3. Estimation of Infection Burden
B. Nosocomial organism specific infection incidence
• Type of microbiology data required
– Clinical culture data only
• Numerator
– Number of hospital onset MDRO infections meeting standard
infection criteria
• Denominator
– 100 pt admissions (incidence); 1000 pt days ( inc. density)
• Surveillance interval
– Monthly
• Location of use
– Specific units (consider use for whole HCF)

20. C. Metrics:
Organism specific, devise associated
associated incidence density :
Useful for assessing the burden of specific device
associated infections.
3. Estimation of Infection Burden

21. 3. Estimation of Infection Burden
c. Organism specific, devise associated incidence density
• Type of microbiology data required
– Clinical culture data only
• Numerator
– Number of devices associated MDRO infections
• Denominator
– 1000 device days
• Surveillance interval
– Monthly
• Location of use
– Specific units (consider use for whole HCF).

22. D. Metrics:
Organism & procedure specific incidence
density
Useful for assessing the burden of specific
procedure associated infections or in specific
populations
3. Estimation of Infection Burden

23. 3. Estimation of Infection Burden
D. Organism & procedure specific incidence density
• Type of microbiology data required
– Clinical culture data only
• Numerator
– Number of procedures associated MDRO infections
• Denominator
– 100 procedures
• Surveillance interval
– Monthly (or quarterly)
• Location of use
– Not applicable

24. 4. Estimating Exposure Burden
A. Metrics:
Overall prevalence or prevalence density
rate based on clinical culture data
Reasonable initial risk assessment,
underestimates hidden reservoirs for MRSA,
VRE & MDR GNB

25. 4. Estimating Exposure Burden
A. Overall prevalence or prevalence density rate based on
clinical culture data
• Type of microbiology data required
– Clinical culture data only
• Numerator
– Number of first MDRO isolated per pt per unit regardless of time
pt spent in the unit and number of pts with history of colonization
or infection
• Denominator
– 100 pt admission (P); 1000 pt days (prevalence density)
• Surveillance interval
– Monthly (or quarterly)
• Location of use
– Specific unit (consider use for whole HCF)

26. 4. Estimating Exposure Burden
B. Metrics
Overall prevalence or prevalence density
rate based on clinical culture and AST
data
Very useful for robust assessment of
intervention if conducting AST

27. 4. Estimating Exposure Burden
B. Overall prevalence or prevalence density rate based on
clinical culture and AST data
• Type of microbiology data required
– Clinical culture and AST data
• Numerator
– Number of first MDRO isolated per pt per unit regardless of time
pt spent in the unit and number of pts with history of colonization
or infection
• Denominator
– 100 pt admission (P); 1000 pt days (prevalence density)
• Surveillance interval
– Monthly
• Location of use
– Specific unit (consider use for whole HCF)

28. 4. Estimating Exposure Burden
C. Metrics
Admission prevalence rate based on clinical
culture data with or without AST
Useful adjunct metrics if there is concern about
importation from community or other HCF

29. 4. Estimating Exposure Burden
C. Admission prevalence rate based on
clinical culture data with or without AST
• Type of microbiology data required
– Clinical culture data with or without AST
• Numerator
– Number of first MDRO isolated per pt per unit < 3 calendar days
after admission to the unit and number of pts with history of
colonization or infection
• Denominator
– 100 pt admissions
• Surveillance interval
– Monthly
• Location of use
– Specific unit (consider use for whole HCF)

30. 4. Estimating Exposure Burden
D. Metrics
Point prevalence rate based on point
prevalence surveys
* Useful adjunct metric for HCF not conducting routine
AST.
* Help provide as estimate of the degree to which
clinical culture data underestimates the full reservoir.
* Could guide HCF when to start AST in select
population or units.
* Very useful in defining high risk areas or population
of an HCF.

31. 4. Estimating Exposure Burden
D. Point prevalence rate based on point prevalence surveys
• Type of microbiology data required
– Clinical culture and AST data
• Numerator
– Number of MDRO isolated per pt per unit or HCF
• Denominator
– 100 pt admissions
• Surveillance interval
– Point in time
• Location of use
– Specific unit (consider use for whole HCF)

32. 5. Quantifying Healthcare Acquisition
A. Metrics:
Incidence or incidence density rate of
hospital onset MDRO
Useful for VRE & MDR GNB during outbreak,
but underestimates the hidden reservoir

33. 5. Quantifying Healthcare Acquisition
A. Incidence or incidence density rate of hospital onset MDRO
• Type of microbiology data required
– Clinical culture data only
• Numerator
– Number of first MDRO isolated per pt per unit > 3 calendar days
after admission to the unit, excluding pts with history of
colonization or infection
• Denominator
– 100 pt admissions (incidence); 1000 pt days ( I. density)
• Surveillance interval
– Monthly
• Location of use
– Specific units (consider use for whole HCF)

34. 5. Quantifying Healthcare Acquisition
B. Metrics:
Incidence or incidence density rate of
hospital onset MDRO
Provides a more useful metric than incidence
based on clinical culture data, if conducting
routine AST

35. 5. Quantifying Healthcare Acquisition
B. Incidence or incidence density rate of hospital onset MDRO
• Type of microbiology data required
– Clinical culture and AST data
• Numerator
– Number of first MDRO isolated per pt per unit > 3 calendar days
after admission to the unit, excluding pts with history of
colonization or infection
• Denominator
– 100 pt admissions (incidence); 1000 pt days ( I. density)
• Surveillance interval
– Monthly
• Location of use
– Specific units (consider use for whole HCF)

36. Category of Measure Basic or
measure Advanced
Tracking Line Listing B
Susceptibility pattern Antibiogram B
Infection Burden Proxy Nosocomial MRSA B
Bacteremic incidence
Nosocomial MRSA A
infection incidence
MRSA device or procedure A
associated infection

37. Category of Measure Basic or
measure Advanced
Exposure Burden Overall MRSA prevalence A
based on clinical cultures
Overall prevalence with
Active Surveillance Testing A
MRSA admission prevalence A
Point prevalence survey A
Healthcare acquisition MRSA incidence based on B (MRSA)
clinical cultures A
Incidence based on AST A

38. These metrics are for monitoring of MDROs
burden in house and monitoring response to
interventions within the healthcare facility.
Should not be used for inter facility comparisons

39. Thank you for your attentionThank you for your attention