Professional Documents
Culture Documents
MDROs
MDROs
RESISTANT ORGANISMS
(MDROs)
Dr Rahul S Kamble, MBBS, MD Microbiology
Diploma Infectious Diseases (UNSW, Australia)
Infection Control course (Harvard Medical School, USA)
International Clinical Tropical Medicine course
(CMC Vellore|Haukeland university McGill university)
International Vaccinology course (CMC Vellore)
Six Sigma Black Belt (Govt of India certified)
Auditor: JCI|NABH|NABL|CSSD|RBNQA|Texila university
PGDBA|PGDHM|PGDCR|PGDMR|PGDOM|
PGDMLS|PGDIM|PGDHI|PGDBI|PGDHA|CCDHHO
Consultant Clinical Microbiologist & Infectious Diseases
Project Lead - Antimicrobial Stewardship 1
Once upon a time, a scientist named Fleming discovered the miracle of
antibiotics…..e, a scientist named Fleming discovered the miracle of antibiotics…..
http://www.pbs.org/wgbh/nova/sciencenow/0303/04-arms-nf.html
“…. the microbes are educated to resist penicillin
and a host of penicillin-fast organisms is bred
out… In such cases the thoughtless person
playing with penicillin is morally responsible for
the death of the man who finally succumbs to
infection with the penicillin-resistant organism. I
hope this evil can be averted.”
Lynfield, The Continued Assault of Antibiotic-Resistance; IDSA Congressional briefing. Accessed 7.27.14 at http://www.idsociety.org/WHDbriefing/
MDRO (multidrug resistant organisms)
MDROs are predominantly bacteria, but can also include viruses, fungi, or
parasites
The names of some MDROs identify resistance to only one drug agent, but
they are frequently resistant to multiple drugs
Source: http://www.ct.gov/dph/cwp. Accessed June 20, 2014 4
Each year nearly 2 million patients in the United States get an infection
in a hospital. Of those patients, about 90,000 die as a result of their
infection. More than 70% of the bacteria that cause hospital-acquired
infections are resistant to at least one of the drugs most commonly used
to treat them. Persons infected with drug-resistant organisms are more
likely to have longer hospital stays and require treatment with second-
or third-choice drugs that may be less effective, more toxic, and/or
more expensive
Clinical importance of
MDROs
•In most instances, MDRO infections have clinical
manifestations that are similar to infections caused by
susceptible pathogens. However, options for treating
patients with these infections are often extremely limited.
Although antimicrobials are now available for treatment
of MRSA and VRE infections, resistance to each new agent
has already emerged in clinical isolates
Increased lengths of stay, costs, and mortality also have been associated with
MDROs.
The type and level of care influence the prevalence of MDROs. ICUs especially
those at tertiary care facilities, may have a higher prevalence Of MDRO infections
than do non-ICU settings
Emergence of Antimicrobial Resistance
Resistant Bacteria
Susceptible
Bacteria
Resistance Gene
Transfer
N
e 8
w
The most challenging
MDROs in Healthcare
Methicillin-resistant Staphylococcus aureus
(MRSA)
Extended-spectrum Beta-lactamase-producing
bacteria (ESBLs)
9
1.Methicillin-Resistant
Staphylococcus Aureus (MRSA)
• MRSA was first isolated in the United States in 1968.
22
Clinical Manifestations
23
• MRSA skin infections can lead to:
• Abscesses
• Cellulitis
24
Risk Factors
Poor functional status Contributing to
Conditions that cause skin breakdown
MRSA
Colonization/Infectio
Presence of invasive devices n for all Facility
Types
Prior antimicrobial therapy
History of colonization
Male gender Pressure ulcers
Disadvantages of Vancomycin
• expensive
• parenteral administration
• ototoxicity
• can potentiate
nephrotoxicity of
aminoglycosides
Treatment
Regimens for • Linezolid has been an alternative to Vancomycin treatment of
MRSA MRSA since 2000 and Administered orally
Infection
Colonization/carrier state of MRSA by
Healthcare Workers
CDC now says we need to decide when to d/c precautions but it may be
prudent to have negative culture(s) prior to d/c of isolation
Why contact precautions for specific
organisms?
Environmental contamination
The Inanimate Environment Can Facilitate
Transmission
X represents VRE culture positive sites
• Treatment
• ceftazidime avibactam , gentamicin, amikacin, colistin,
tigecycline and fosfomycin
• Bacterial enzymes capable of hydrolysing
Extended- and thus conferring resistance to all
spectrum beta- penicillins, first-, second-, & third generation
lactamase- cephalosporins, and aztreonam.
producing • Resitance to ceftriaxone or cefotaxime is the
screening criteria for ESBL
bacteria
• Treatment
(ESBLs)
• Carbapenems, BLBLIs (piptaz, zavicefta)
•Enzymes produced by certain
bacteria that provide resistance to
certain antibiotics
Beta-
Lactamases:
What are they ? •Produced by both gram positive and
gram negative bacteria
Examples
•Penicillin's:
–Penicillin, amoxicillin, ampicillin
•Cephalosporin's:
–Cephalexin,Cefuroxime,Ceftriaxone
•Carbapenems:
–Imipenem, meropenem
• Mechanism of Action
•Ceftazidime
•Cefotaxime
•Ceftriaxone
•Aztreonam
•Genes encoding for ESBLs are frequently located on plasmids that also carry resistance genes for:
•Aminoglycosides
•Tetracycline
•TMP-SULFA
•Chloramphenicol
•Fluoroquinolones
Essential vocabulary for
phenotypic detection of
ESBLs, AmpCs and
carbapenemases 2/3
Essential vocabulary for phenotypic detection of ESBLs,
AmpCs and carbapenemases 3/3
F/C F/C F/C F/C F/C F/C F/C F/C F/C F/C F/C POS
0.06/4 0.12/4 0.25/4 0.5/4 1/4 2/4 4/4 8/4 16/4 32/4 64/4 CTRL
B E TA - L A C TA M A S E
PHENOTYPES: EFSA CRITERIA
Genotypic detection of
ESBLs, AmpCs and carbapenemases
FEATURES TO REMEMBER
• •Cephamycins:
• –Cefoxitin
• –Cefotetan
• •Carbapenems:
• –Meropenem
• –Imipenem
• Limited clinical use due to nephro- and neurotoxicity main use in production animal industry
• Resurgence in last decade due to MDR Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter spp.
Total consumption of colistin in humans (…) has doubled in some of EU/EEA countries between 2010 and 2014
following the rise in MDR Gram negative pathogens involved in healthcare-associated infections. – EMA, 2016
Escherichia coli
Salmonella spp. Intrinsically resistant bacteria:
Klebsiella spp. Gram-positive bacteria
Acinetobacter spp. Proteus mirabilis
Enterobacter spp. Serratia marcescens
Pseudomonas aeruginosa Other
Haemophilus influenzae
Colistin resistance
•Acquired colistin resistance is mainly the consequence of Gene Publication
Gene
accession
Variants
•inaccessibility
dissemination of
resistance mcr-8 Wang X, 2018 MG736312.1 8.2 and 8.4
Detection of
Colistin
Resistance
Phenotypic
methods
Phenotypic methods
Phenotypic methods
Quality control is essential
Quality control of colistin must be performed both with a susceptible QC strain (E. coli ATCC 25922
or P. aeruginosa ATCC 27853) and with the colistin-resistant E. coli NCTC 13846 (mcr-1 positive).
4 mg/L
E. coli NCTC 13846 (only occasionally 2 or 8 mg/L)
Effective
Optimize Diagnosis
Use & Treatment
Antimicrobial Use
Steps to Prevent Antimicrobial
Resistance:
Prevent Infection
1. Vaccinate
1 2 3 4 5 6 7 8 9
2. Get the catheters
out Use Practice Use Treat Treat Know Stop Isolate Break
Diagnose and Treat • Use • Practice • Use local • Treat • Treat • Know when • Stop • Isolate the • Break the
Infection Effectively Antimicrobi
als Wisely
antimicrobi
al control
data infection,
not
infection,
not
to say “no”
to vanco
treatment
when
pathogen chain of
• contagion
contamina colonizatio infection is
tion n cured or
unlikely
Actions:
give influenza / pneumococcal vaccine to at-risk patients before discharge
get influenza vaccine annually
Need for Healthcare Personnel Immunization
Programs: Influenza Vaccination Rates (1996-97)
% Vaccinated
Hospitalized for
pneumonia 35% vaccinated 20% vaccinated
during influenza
season**
Prevent Infection
Step 2: Get the catheters out
•Actions:
• use catheters only when essential
• use the correct catheter
• use proper insertion & catheter-care protocols
• remove catheters when not essential
Scanning
Electron Micrograph
Diagnose & Treat Infection Effectively
Step 3: Target the pathogen
Actions:
target definitive therapy to known
target empiric therapy to likely
culture the patient pathogens and antimicrobial
pathogens and local antibiogram
susceptibility test results
Inappropriate Antimicrobial Therapy:
Impact on Mortality
Inappropriate
45.2% Antimicrobial Therapy
% inappropriate
Patient Group
Step 4: Access the experts
Infectious Diseases
Specialists
Healthcare Infection Control
Epidemiologists Professionals
Clinical Optimal
Pharmacists Patient Care
Clinical
Clinical Pharmacologists
Microbiologists
Surgical Infection
Experts
Use Antimicrobials Wisely
• Fact:
The prevalence of resistance can vary by time, locale, patient
population, hospital unit, and length of stay.
Step 7: Treat infection, not contamination
• Actions:
• use proper antisepsis for blood & other cultures
• culture the blood, not the skin or catheter hub
• use proper methods to obtain & process all cultures
•
Step 8: Treat infection, not colonization
• Actions:
• treat bacteremia, not the catheter tip or hub
• treat pneumonia, not the tracheal aspirate
• treat urinary tract infection, not the indwelling catheter
Fact:
“no” to Vanco
Step 10: Stop antimicrobial treatment
• Actions:
• when infection is cured
• when cultures are negative and infection is unlikely
• when infection is not diagnosed
Step 11: Isolate the pathogen
Ignaz Philipp
Semmelweis
(1818-65)
Chlorinated lime hand antisepsis
Prevention and Control of MDRO
transmission
• Successful control of MDROs has been documented using a variety of combined interventions.
These include:
• - Improvements in hand hygiene,
• - Use of Contact Precautions until patients are culture-negative for a target MDRO,
• - Active surveillance cultures (ASC),
• - Education,
• - Enhanced environmental cleaning, and improvements in communication about patients with
MDROs within and between healthcare facilities.
Infection control practices and the
campaign to prevent multi-drug resistance
• Problem!
• Unrestricted use of antibiotics in the community:
• Role of physicians-evidence based guidelines and protocols
• Role of pharmacists-policies (antibiotics should not be over the counter
drugs!)
• Role of public-education
• Role of the ministry of health-rules and regulations
Infection control practices and the
campaign to prevent multi-drug resistance
• Problem!
• Lack of National Nosocomial Infection Surveillance (NNIS) system (governmental and non-governmental)
• Problem!
• Do we have adequate Infectious Diseases Expert Resources ?
• - Infectious Diseases Specialists
• - Infection Control Professionals
• - Clinical Pharmacologists
• - Clinical Microbiologists
• - Health care Epidemiologists
Protect patients…protect healthcare
personnel… promote quality healthcare!
55
THANK YOU