Multidrug-Resistant%20Nosocomial%20Infections%20in%20the%20PICU%20:%20how%20to%20deal%20with%20it? - PowerPoint PPT Presentation

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Multidrug-Resistant%20Nosocomial%20Infections%20in%20the%20PICU%20:%20how%20to%20deal%20with%20it?

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Title: Multidrug-Resistant%20Nosocomial%20Infections%20in%20the%20PICU%20:%20how%20to%20deal%20with%20it?


1
  • Multidrug-Resistant Nosocomial Infections in the
    PICU how to deal with it?

Somchai Suntornlohanakul
2
Scope of Presentation
  • Introduction Background of MDRO
  • Epidemiology of MDRO
  • MDRO prevention and control
  • Preventing nosocomial infection in PICU
    practical point for Nurse

3
Multidrug-Resistant Nosocomial Infections in the
PICU how to deal with it?
  • Multidrug-resistant organisms (MDRO), including
    methicillin-resistant 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

4
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

5
Successful prevention and control of MDRO
Scientific Leadership
Financial Support
Administrative Leadership
Human Resource Commitment
  • Resources should include expert consultation,
    laboratory support, adherence monitoring, and
    data analysis

6
  • 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

7
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

8
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, and mortality
    also have been associated with MDRO

9
MRSA and MSSA
  • MRSA may behave differently from other MDRO
  • MRSA colonized patients more frequently develop
    symptomatic infections
  • Higher case fatality rates have been observed for
    certain MRSA infections, including bacteremia,
    poststernotomy mediastinitis, and surgical site
    infections

10
Epidemiology of MDRO
  • Prevalence of MDRO varies temporally,
    geographically,
  • and by healthcare setting
  • The type and level of care also influence the
    prevalence
  • of MDRO
  • Antimicrobial resistance rates are also strongly
  • correlated with hospital size, tertiary-level
    care, and
  • facility type

11
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
  • lt 4 of patients were colonized with MRSA or VRE
  • 10-24 were colonized with ceftazidime- or
    aminoglycoside-resistant Gram-negative bacilli
  • lt 3 were colonized with ESBL-producing Gram
    negative bacilli.
  • MDRO burden is greatest in adult hospital
    patients, but require similar control efforts

12
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 and adherence to
    prevention efforts

13
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

14
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, include
    chronic sinusitis, upper respiratory infection,
    and dermatitis

15
MDRO Prevention and Control
16
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

17
Prevention and Control of MDRO transmission
  • Successful control of MDRO has been documented in
    the
  • US and abroad 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

18
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19
Control Interventions
  • Administrative support
  • MDRO Education
  • Judicious Antimicrobial Use
  • MDRO Surveillance
  • Infection Control Precautions to Prevent
    Transmission
  • Environmental Measures
  • Decolonization

20
Administrative Support
  • Implementing system changes to ensure prompt and
    effective communications
  • Providing the necessary number and appropriate
    placement of hand washing sinks and
    alcohol-containing hand rub dispensers in the
    facility
  • Maintaining staffing levels appropriate to the
    intensity of care required

21
Administrative Support
  • Enforcing adherence to recommended infection
    control practices for MDRO control
  • Adherence monitoring
  • Participation in regional or national coalitions
    to combat emerging or growing MDRO problems

22
Control Interventions
  • Administrative support
  • MDRO Education
  • Judicious Antimicrobial Use
  • MDRO Surveillance
  • Infection Control Precautions to Prevent
    Transmission
  • Environmental Measures
  • Decolonization

23
MDRO Education
  • Encourage a behavior change through improved
    understanding of the problem MDRO that the
    facility was trying to control
  • Facility-wide, unit-targeted, and informal,
    educational interventions
  • Patient outcomes
  • Antibiotic choice Resistance
  • Infection control

24
Control Interventions
  • Administrative support
  • MDRO Education
  • Judicious Antimicrobial Use
  • MDRO Surveillance
  • Infection Control Precautions to Prevent
    Transmission
  • Environmental Measures
  • Decolonization

25
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

26
Judicious Antimicrobial Use
  • Focus on effective antimicrobial treatment of
    infections
  • Use of narrow spectrum agents
  • 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

27
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

28
Control Interventions
  • Administrative support
  • MDRO Education
  • Judicious Antimicrobial Use
  • MDRO Surveillance
  • Infection Control Precautions to Prevent
    Transmission
  • Environmental Measures
  • Decolonization

29
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

30
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

31
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
    antimicrobial prescribing practices

32
1.2 MDRO Incidence Based on Clinical Culture
Results
  • Calculate measures of incidence of MDRO isolates
    in specific populations or patient care locations
    (e.g. new MDRO isolates/1,000 patient days, new
    MDRO isolates per month)
  • Useful for monitoring MDRO trends and assessing
    the impact of prevention programs
  • Based solely on positive culture results without
    accompanying clinical information

33
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

34
MDRO Incidence Based on Clinical Culture Results
  • Despite limitations, incidence measures were
    highly correlated with actual MDRO transmission
    rates derived from information using ASC
  • The results suggest that incidence measures based
    on clinical cultures alone might be useful
    surrogates for monitoring changes in MDRO
    transmission rates

35
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

36
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

37
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, detection of
    colonization may be delayed or missed completely
    if culture results obtained in the course of
    routine clinical care

38
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 about use of additional
    isolation measures triggered by a positive
    culture (e.g. Contact Precautions)
  • mechanism for assuring adherence to the
    additional isolation measures

39
Populations targeted for ASC
  • Not well defined
  • High risk for MDRO colonization based on
  • location (e.g. PICU with high MDRO rates)
  • antibiotic exposure history
  • presence of underlying diseases
  • prolonged duration of stay
  • 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
    colonization

40
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 to
    detect silent transmission
  • Some based follow-up cultures on the presence of
    certain risk factors for MDRO colonization

41
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 peri-rectal or rectal swabs alone or in
    combination with oro-pharyngeal, endotracheal, or
    wound cultures
  • 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

42
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.

43
Control Interventions
  • Administrative support
  • MDRO Education
  • Judicious Antimicrobial Use
  • MDRO Surveillance
  • Infection Control Precautions to Prevent
    Transmission
  • Environmental Measures
  • Decolonization

44
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

45
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

46
Contact Precautions
  • Prevent transmission of infectious agents
    transmitted by direct or indirect contact with
    the patient or the patients 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

47
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
    patients environment
  • Donning gown and gloves upon room entry and
    discarding before exiting the patient room is done

48
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

49
Duration of Contact Precautions
  • Remains an unresolved issue
  • In the context of an outbreak, prudence would
    dictate that Contact Precautions be used
    indefinitely for all previously infected and
    known colonized patients

50
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 the
    duration of stay in the setting where they were
    first implemented

51
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

52
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

53
Control Interventions
  • Administrative support
  • MDRO Education
  • Judicious Antimicrobial Use
  • MDRO Surveillance
  • Infection Control Precautions to Prevent
    Transmission
  • Environmental Measures
  • Decolonization

54
Contaminated surfaces increase cross-transmission
x
x
x
x
x
x
x
x
x
55
Control Interventions
  • Administrative support
  • MDRO Education
  • Judicious Antimicrobial Use
  • MDRO Surveillance
  • Infection Control Precautions to Prevent
    Transmission
  • Environmental Measures
  • Decolonization

56
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

57
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

58
Other Questions
  • Impact on other MDRO from interventions targeted
    to one MDRO
  • Costs
  • Feasibility
  • Factors that influence selection of MDRO control
    measures
  • Differences of opinion on the optimal strategy to
    control MDRO

59
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

60
  • 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

61
Intensification of MDRO control activities
Problem Assessment
Evaluate the Effectiveness of measures
Governing body and medical staff
Select appropriate additional control measures
Expert
Intervention Implementation
On going Surveillance
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