Multidrug-Resistant Nosocomial Infections in the PICU : how to deal with it?

Somchai Suntornlohanakul

Scope of Presentation

• Introduction & Background of MDRO • Epidemiology of MDRO • MDRO prevention and control • Preventing nosocomial infection in PICU: practical point for Nurse

Multidrug-Resistant Nosocomial Infections in the PICU : how to deal with it?

• Multidrug-resistant organisms methicillin-resistant (MDRO), including Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and certain Gram-negative bacill (GNB) have important infection control implications • The prevention and control of MDRO is a national priority

The prevention and control of MDRO is a national priority • The administration of healthcare organizations and institutions should ensure that – appropriate strategies are fully implemented – regularly evaluated for effectiveness – adjusted such that there is a consistent decrease in the incidence of targeted MDRO

Successful prevention and control of MDRO

Scientific Leadership Administrative Leadership Human Resource Commitment Resources should include expert consultation, laboratory support, adherence monitoring, and data analysis Financial Support

• Infection prevention and control professionals have found that healthcare personnel (HCP) are more receptive and adherent to the recommended control measures when organizational leaders participate in efforts to reduce MDRO transmission

Multidrug-Resistant Organisms

MDRO are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents.

Although the names of certain MDRO describe resistance to only one agent (e.g., MRSA, VRE, [ESBL]-producing or intrinsically resistant Gram-negative bacilli), these pathogens are frequently resistant to most available antimicrobial agents

Clinical importance of MDRO

• In most instances, MDRO infections have clinical manifestations that are similar to infections caused by susceptible pathogens • Options for treating patients with these infections are often extremely limited • Increased lengths of stay , costs, have been associated with MDRO and mortality also

MRSA and MSSA

• MRSA may behave differently from other MDRO • MRSA colonized patients more frequently develop symptomatic infections • Higher case fatality rates surgical site infections have been observed for certain MRSA infections, including bacteremia, poststernotomy mediastinitis, and

Epidemiology of MDRO

• Prevalence of MDRO varies temporally, geographically , and by healthcare setting • The type and level of care of MDRO also influence the prevalence • Antimicrobial resistance rates are also strongly correlated with hospital size, tertiary-level care, and facility type

Epidemiology of MDRO

• Prevalence of target MDRO in the adult patient is greater than pediatric population. • Point prevalence surveys conducted by the Pediatric Prevention Network (PPN) in eight U.S. PICU and 7 U.S. NICU in 2000: – < 4% of patients were colonized with MRSA or VRE – 10-24% were colonized with ceftazidime- or aminoglycoside resistant Gram-negative bacilli – < 3% were colonized with ESBL-producing Gram negative bacilli.

• MDRO burden is greatest in adult hospital patients, but require similar control efforts

Important concepts in transmission

• Transmission and persistence of the resistant strain is determined by – the availability of vulnerable patients – selective pressure exerted by antimicrobial use – increased potential for transmission from larger numbers of colonized or infected patients (“ colonization pressure ”) – impact of implementation prevention efforts and adherence to

Important concepts in transmission

• Ample epidemiologic evidences suggest that MDRO are carried from one person to another via the hands of HCP • Without adherence to recommendations for hand hygiene and glove use , HCP are more likely to transmit MDRO to patients • Strategies to increase and monitor adherence are important components of MDRO control programs

Role of colonized HCP in MDRO transmission • Rarely , HCP may introduce an MDRO into a patient care unit • Occasionally , HCP can become persistently colonized with an MDRO, but these HCP have a limited role in transmission , unless other factors are present. • Factors that can facilitate transmission dermatitis , include chronic sinusitis, upper respiratory infection, and

MDRO Prevention and Control

MDRO Prevention of Infections

• Campaign to Reduce Antimicrobial Resistance in Healthcare Settings • A multifaceted, evidence-based approach with four parallel strategies: – infection prevention – accurate and prompt diagnosis and treatment – prudent use of antimicrobials – prevention of transmission

Prevention and Control of MDRO transmission • Successful control of MDRO US and abroad has been documented in the using a variety of combined interventions – Hand hygiene – Contact Precautions – Active surveillance cultures (ASC) – Education – Enhanced environmental cleaning – Improvements in communication about patients with MDRO within and between healthcare facilities

Control Interventions

• Administrative support • MDRO Education • Judicious Antimicrobial Use • MDRO Surveillance • Infection Control Precautions to Prevent Transmission • Environmental Measures • Decolonization

Administrative Support

• Implementing system changes and effective communications to ensure prompt • Providing the necessary number and appropriate placement of hand washing sinks and alcohol containing hand rub dispensers in the facility • Maintaining staffing levels intensity of care required appropriate to the

Administrative Support

• Enforcing adherence to recommended infection control practices for MDRO control • Adherence monitoring • Participation in regional or national coalitions combat emerging or growing MDRO problems to

Control Interventions

• Administrative support • MDRO Education • Judicious Antimicrobial Use • MDRO Surveillance • Infection Control Precautions to Prevent Transmission • Environmental Measures • Decolonization

MDRO Education

• Encourage a behavior change understanding of the problem MDRO that the facility was trying to control through improved • Facility-wide, unit-targeted, and informal, educational interventions – Patient outcomes – Antibiotic choice & Resistance – Infection control

Control Interventions

• Administrative support • MDRO Education • Judicious Antimicrobial Use • MDRO Surveillance • Infection Control Precautions to Prevent Transmission • Environmental Measures • Decolonization

Pharmacokinetic (PK)/Pharmacodynamic (PD) considerations • The goal of antibiotic therapy is to achieve complete bacterial eradication and to minimise the risk of resistance selection • The dosing regimen is influenced by its PK profile and the susceptibility of the target pathogen • To predict bacteriological and clinical efficacy and help to identify the correct dose and dosing interval

Judicious Antimicrobial Use

• Focus on effective antimicrobial treatment infections • Use of narrow spectrum agents of • Treatment of infections and not contaminants • Avoiding excessive duration of therapy • Restricting use of broad-spectrum or more potent antimicrobials to treatment of serious infections when the pathogen is not known

Strategies for influencing antimicrobial prescribing patterns • Education • Formulary restriction • Prior-approval programs • Automatic stop orders • Academic interventions to counteract pharmaceutical influences on prescribing patterns • Computer-assisted management programs • Active efforts to remove redundant antimicrobial combinations

Control Interventions

• Administrative support • MDRO Education • Judicious Antimicrobial Use • MDRO Surveillance • Infection Control Precautions to Prevent Transmission • Environmental Measures • Decolonization

MDRO surveillance

• Surveillance is a critically important component of any MDRO control program – allowing detection of newly emerging pathogens – monitoring epidemiologic trends – measuring the effectiveness of interventions • MDRO surveillance strategies – surveillance of clinical microbiology laboratory results obtained as part of routine clinical care – active surveillance cultures (ASC) to detect asymptomatic colonization

1: Surveillance for MDRO Isolated from routine clinical cultures 1.1 Antibiograms 1.2 MDRO Incidence Based on Clinical Culture Results 1.3 MDRO Infection Rates 1.4 Molecular typing of MDRO isolates

1.1 Antibiograms

• Monitoring of clinical microbiology isolates resulting from tests ordered as part of routine clinical care • Detect emergence of new MDRO • Prepare facility- or unit-specific summary antimicrobial susceptibility reports that describe pathogen-specific prevalence of resistance among clinical isolates • Useful to monitor for changes in known resistance patterns • Provide clinicians with information to guide prescribing practices antimicrobial

1.2 MDRO Incidence Based on Clinical Culture Results • Calculate measures of per month) incidence of MDRO isolates in specific populations or patient care locations (e.g. new MDRO isolates/1,000 patient days, new MDRO isolates • Useful for monitoring MDRO trends and assessing impact of prevention programs the • Based solely on positive culture results without accompanying clinical information

MDRO Incidence Based on Clinical Culture Results • Do not distinguish colonization from infection • Culture obtained from a patient several days after admission to a given unit or facility does not establish that the patient acquired colonization in that unit • Acquire MDRO colonization may remain undetected by clinical cultures

MDRO Incidence Based on Clinical Culture Results • Despite limitations, highly correlated incidence measures rates derived from information were with actual MDRO transmission using ASC • The results suggest that incidence measures based on clinical cultures alone might be useful surrogates for monitoring changes in MDRO transmission rates

1.3 MDRO Infection Rates

• Requires investigation of clinical circumstances surrounding a positive culture to distinguish colonization from infection • Can be particularly helpful in defining the clinical impact of MDRO within a facility

1.4 Molecular typing of MDRO isolates

• Many investigators have used molecular typing of selected isolates to confirm clonal transmission to enhance understanding of MDRO transmission and the effect of interventions within their facility

2. Surveillance for MDRO by Detecting Asymptomatic Colonization • Active Surveillance Cultures (ASC) to identify patients who are colonized with a targeted MDRO • Based upon that, for some MDRO, clinical care detection of colonization may be delayed or missed completely if culture results obtained in the course of routine

Use of ASC incorporated into MDRO prevention programs • Support for successful implementation includes – personnel to obtain the appropriate cultures – microbiology laboratory personnel to process the cultures – mechanism for communicating results to caregivers – concurrent decisions measures triggered by a positive culture (e.g. Contact Precautions) about use of additional isolation – mechanism for assuring adherence isolation measures to the additional

Populations targeted for ASC

• Not well defined • High risk for MDRO colonization – location (e.g. PICU with high MDRO rates) – antibiotic exposure history – presence of underlying diseases – prolonged duration of stay colonization based on – exposure to other MDRO colonized patients – patients transferred from other facilities known to have a high prevalence of MDRO carriage, or having a history of recent hospital or nursing home stays • All patients admitted to units experiencing MDRO

Optimal timing and interval of ASC

• Not well defined • Cultures were obtained at the time of admission to the hospital or intervention unit • Some obtain cultures on a periodic basis detect silent transmission to • Some based follow-up cultures on the presence of certain risk factors for MDRO colonization

Methods for obtaining ASC

• Must be carefully considered, and vary depending upon the MDRO of interest • MRSA : cultures of the nares, peri-rectal and wound cultures can identify additional carriers • VRE : Stool, rectal, or peri-rectal swabs • MDR-GNB cultures : peri-rectal or rectal swabs alone or in combination with oro-pharyngeal, endotracheal, or wound • The absence of standardized screening media for many Gram negative bacilli can make the process of isolating a specific MDR-GNB a relatively labor-intensive process

Rapid detection methods

• Using conventional culture methods can result in a delay of 2-3 days and the desired infection control measures could be delayed . • If empiric precautions are used pending negative surveillance culture results, precautions may be unnecessarily implemented.

Control Interventions

• Administrative support • MDRO Education • Judicious Antimicrobial Use • MDRO Surveillance • Infection Control Precautions to Prevent Transmission • Environmental Measures • Decolonization

Infection Control Precautions

• Standard Precautions • Contact Precautions • Cohorting and other MDRO control strategies • Duration of Contact Precautions • Impact of Contact Precautions on patient care and well-being

Standard Precautions

• An essential role in preventing MDRO transmission • Colonization with MDRO is frequently undetected • Standard Precautions must be used to prevent transmission from potentially colonized patients • Hand hygiene is an important component of Standard Precautions

Contact Precautions

• Prevent transmission of infectious agents transmitted by direct or indirect contact with the patient or the patient’s environment • A single-patient room is preferred • When a single-patient room is not available, consultation with infection control is necessary to assess the various risks associated with other patient placement options

Contact Precautions

• HCP should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment • Donning gown and gloves upon room entry and discarding before exiting the patient room is done

Cohorting and other MDRO control strategies • Cohorting of patients • Cohorting of staff • Use of designated beds or units, unit closure were necessary to control transmission

Duration of Contact Precautions

• Remains an unresolved issue • In the context of colonized patients an outbreak , prudence would dictate that Contact Precautions be used indefinitely for all previously infected and known

Duration of Contact Precautions

• If ASC are used to detect and isolate patients colonized with MRSA or VRE • There is no decolonization of these patients • Contact Precautions would be used for first implemented the duration of stay in the setting where they were

Duration of Contact Precautions

• In general, discontinue contact precautions when – three or more surveillance cultures for MDRO are repeatedly negative – over the course of a week or two in a patient who has not received antimicrobial therapy for several weeks – in the absence of a draining wound, profuse respiratory secretions

Impact of Contact Precautions on patient care and well-being • HCP, attending physicians, were half as likely to enter the rooms of or examine patients on contact precautions • Had significantly more preventable adverse events • Increased anxiety and depression scores • Expressed greater dissatisfaction with their Rx • Efforts must be made by the healthcare team to counteract these potential adverse effects

Control Interventions

• Administrative support • MDRO Education • Judicious Antimicrobial Use • MDRO Surveillance • Infection Control Precautions to Prevent Transmission • Environmental Measures • Decolonization

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Contaminated surfaces increase cross-transmission

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Control Interventions

• Administrative support • MDRO Education • Judicious Antimicrobial Use • MDRO Surveillance • Infection Control Precautions to Prevent Transmission • Environmental Measures • Decolonization

Decolonization

• Decolonization entails treatment of persons colonized with a specific MDRO, usually MRSA, to eradicate carriage of that organism • Decolonization regimens are not sufficiently effective to warrant routine use

Decolonization

Factor that limit the utility of decolonization – Identification of candidates requires surveillance cultures – Candidates receiving the treatment must receive follow-up cultures to ensure eradication – Re-colonization with the same strain and emergence of resistance to treatment can occur

Other Questions

• Impact on other MDRO to one MDRO • Costs from interventions targeted • Feasibility • Factors that influence selection of MDRO control measures • Differences of opinion on the optimal strategy control MDRO to

Factors that influence selection of MDRO control measures

• No single approach to the control of MDRO is appropriate for all healthcare facilities • Factors influence the choice of interventions to be applied within an institution, including – Type and significance of problem MDRO within the institution – Population and healthcare-settings

• Selection of interventions for controlling MDRO transmission should be based on assessments of the local problem , the prevalence of various MDRO and feasibility • Individual facilities should seek appropriate guidance and adopt effective measures that fit their circumstances and needs

Intensification of MDRO control activities Problem Assessment Evaluate the Effectiveness of measures Governing body and medical staff Select appropriate additional control measures Intervention Implementation On going Surveillance Expert