Infection Control Aspects of VRE & ESBL-producing Organisms - PowerPoint PPT Presentation

1 / 29
About This Presentation
Title:

Infection Control Aspects of VRE & ESBL-producing Organisms

Description:

Infection Control Aspects of VRE & ESBL-producing Organisms Dr Miles Denton Consultant Microbiologist Leeds Teaching Hospitals NHS Trust ESBL-producing organisms ... – PowerPoint PPT presentation

Number of Views:372
Avg rating:3.0/5.0
Slides: 30
Provided by: pathologi4
Category:

less

Transcript and Presenter's Notes

Title: Infection Control Aspects of VRE & ESBL-producing Organisms


1
Infection Control Aspects of VRE ESBL-producing
Organisms
  • Dr Miles Denton
  • Consultant Microbiologist
  • Leeds Teaching Hospitals NHS Trust

2
ESBL-producing organisms
  • Escherichia coli CTX-M
  • Klebsiella species TEM/SHV variants
  • Pseudomonas aeruginosa
  • Acinetobacter baumanii
  • Other Enterobacteriaceae

3
Why are VRE and ESBL-producing organisms
important?
  • Increasing clinical problem
  • They cause outbreaks, particularly in critical
    areas e.g. ICUs, neonatology
  • Often multi-resistant - can be difficult to treat
  • Associated with increased mortality
  • Associated with increased LOS

4
Available guidance
  • VRE
  • Guidelines for the control of glycopeptide-resista
    nt enterococci in hospitals. Combined Working
    Party HIS/ICNA/BSAC, 2004.
  • ESBLs
  • No equivalent guidance

5
VRE UK situationVancomycin resistance in
Enterococcal bacteraemia, England, Wales,
Northern Ireland, Voluntary reporting to HPA
Centre for Infections, 2003-4.
6
VRE European situationEARSS Annual Report 2002
7
ESBLs VRE an emerging problem Diekema et al,
Clin Infect Dis 2004 38 78-85
8
ESBLs VRE association with hospital size and
complexityDiekema et al, Clin Infect Dis 2004
38 78-85
9
ESBLs VRE association with hospital size and
complexityDiekema et al, Clin Infect Dis 2004
38 78-85
10
ESBLs European situationEARSS Annual Report
2002
11
ESBLs an emerging problemGlasswell et al,
Healthcare-associated Infection and Antimicrobial
Resistance Dept Antimicrobial Resistance
Monitoring and Reference Laboratory, Health
Protection Agency, Colindale, London
12
ESBLs an emerging problemGlasswell et al,
Healthcare-associated Infection and Antimicrobial
Resistance Dept Antimicrobial Resistance
Monitoring and Reference Laboratory, Health
Protection Agency, Colindale, London
13
Bacteraemia isolates Leeds Teaching Hospitals
Trust, 2004
ESBLs have become a much more significant
clinical problem than VRE
14
Scottish trends and routine diagnostic detection
of ESBLs. FM MacKenzie. SCIEH Weekly Report
2004/50
15
Identification of ESBLs (and VRE) is a problem.
16
Laboratory issues
  • Isolation/identification of ESBL-positive
    organisms
  • Laboratory Detection and Reporting of Bacteria
    with Extended Spectrum Beta-lactamases, QSOP 51.
    Issued by Standards Unit, Evaluation Standards
    Laboratory, Health Protection Agency, February
    2005
  • Many gram negative organisms not subjected to
    susceptibility tests does this matter?
  • Many gram negative organisms not routinely
    identified to species level does this matter?
  • Are all enterococci tested versus vancomycin?
  • Recognition of outbreaks availability of
    genotyping
  • Concept of high risk areas (e.g. ICU) no
    longer valid with emergence of CTX-M in the
    community

17
Infection Control Strategies
  • Handwashing
  • Patient screening
  • Staff screening
  • Environmental screening
  • Isolation rooms/wards
  • Environmental cleaning
  • Ward closure
  • Antibiotic prescribing policies
  • Education
  • Others

?
18
Guidelines for the control of glycopeptide-resista
nt enterococci in hospitals. Combined Working
Party HIS/ICNA/BSAC, 2004.
  • Risk factors for GRE infection outlined
  • Previous antibiotic therapy glycopeptides,
    cefalosporins
  • Prolonged hospital stay
  • Admission to ICU, haematology, renal, liver
  • Carriage large bowel
  • Transmitted via hands colonised/ infected
    patients, contaminated environment

19
Managing hospital outbreaks of GRE Combined
Working Party HIS/ICNA/BSAC, 2004.
  • Screening patients faeces (rather than rectal
    swabs)
  • Urine, wound, line sites, HVSs also used
  • Uncertainty regarding media/method
  • Incorporate bile salts and selective agents
  • Optimum vancomycin concentration debated NCCLS
    recommends 6mg/l
  • Outbreak isolates to be typed - PFGE

20
Managing hospital outbreaks of GRE Combined
Working Party HIS/ICNA/BSAC, 2004.
  • Managing patients
  • Differentiate colonisation from infection
  • Use antibiotics ONLY for infection
  • Remove/drain sources of infection
  • Gut carriage can persist for months/years
  • Attempts at clearance are usually unsuccessful
  • Screening staff for stool carriage is of no value

21
Managing hospital outbreaks of GRE Combined
Working Party HIS/ICNA/BSAC, 2004.
  • Risk assessment sporadic/epidemic/endemic
  • Area involved, infection/colonisation
  • Hand hygiene paramount
  • Disinfectant-based products more effective than
    soap
  • Alcohol gel most convenient provided hands not
    visibly soiled

22
Managing hospital outbreaks of GRE Combined
Working Party HIS/ICNA/BSAC, 2004.
  • Isolation dependent on risk assessment, single
    rooms or cohorts
  • Diarrhoea/incontinence
  • Thorough cleaning or room/bay/ward after incident
  • Optimal cleaning regimen undefined e.g. 500ppm
    available chlorine/1-2 phenolics
  • Laundry bedding/curtains
  • Inform colleagues receiving transfers
  • Appropriate use of antibiotics glycopeptides
    and cefalosporins

23
A simultaneous outbreak on a neonatal unit of two
strains of multiply antibiotic resistant
Klebsiella pneumoniae controllable only by ward
closure. Macrae et al, J Hosp Infect 2001 49
183-92
  • Outbreak of two amoniglycoside-resistant K.
    pneumoniae strains (one ESBL)
  • UK neonatal unit 22 neonates affected, one died

24
A simultaneous outbreak on a neonatal unit of two
strains of multiply antibiotic resistant
Klebsiella pneumoniae controllable only by ward
closure. Macrae et al, J Hosp Infect 2001 49
183-92
  • Outbreak control group
  • Closed to transfers from other units
  • Unable to cohort allocation of nurses
  • Glove/gowns for all patient contacts
  • Alcohol chlorhexidine handrub
  • Weekly screening of all patients
  • Empiric therapy changed from gent/pen to amik/mer
  • Environmental screening
  • Improved cleaning
  • Outbreak continued

25
A simultaneous outbreak on a neonatal unit of two
strains of multiply antibiotic resistant
Klebsiella pneumoniae controllable only by ward
closure. Macrae et al, J Hosp Infect 2001 49
183-92
  • Ward closed to admissions
  • Satellite unit opened to manage all sick neonates
    born at the hospital, staff screened negative for
    enteric carriage
  • Second satellite unit opened to take remaining
    KP patients to allow complete closure/cleaning
    of neonatal unit
  • Re-screening of environment reopened
  • All new admissions screened for carriage of
    multiply resistant GNBs

26
Rectal carriage of ESBL-producing organisms on
the General and Neurosurgical ICUs, Leeds General
Infirmary, MZali et al, ECCMID 2005
Ten (62) of the 16 patients ESBL on admission
had been in hospital lt 48h
27
Impact of a county-wide outbreak of
ESBL-producing Eschrichia coli. Warren et al,
SCIEH Weekly Report 38 2004/50
  • Fourteen month period outbreak of
    CTX-M-producing Escherichia coli in Shropshire
  • Four subclones of E. coli O25
  • High prevalence of quin/trim resistance (98)
  • Uropathogenic
  • 281 patients infected, 16 had bacteraemia
  • 50 of cases community-based
  • 5/16 bacteraemic patients died, 64/244 other
    evaluable patients died
  • One third of community patients no hospital
    link
  • Restrictions on the reporting of cefs/quins
  • Increased use of carbapenems
  • Control hampered by lack of isolation facilities
    and high bed-occupancy rates

28
Global spread of vacomycin-resistant Enterococcus
faecium from distinct genetic complex Willems et
al, Emerg Infect Dis 2005 11 821-9.
Many outbreaks of GRE may be due to related group
of highly successful strains COMPLEX-17 Ampicill
in-resistant Pathogenicity island Association
with outbreaks Found globally mainly Europe
and USA
0 Animal surveillance 1 Human community
surveillance 2 Human hospital surveillance 3
Human hospital clinical 4 Hospital outbreak
samples
29
(No Transcript)
Write a Comment
User Comments (0)
About PowerShow.com