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

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

Somchai Suntornlohanakul
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Scope of Presentation

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

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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

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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

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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

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• 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

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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

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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

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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

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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

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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

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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

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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

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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

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MDRO Prevention and Control
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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

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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

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Control Interventions

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

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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

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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

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Control Interventions

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

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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

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Control Interventions

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

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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

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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

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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

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Control Interventions

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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Control Interventions

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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
x
x
x
x
x
x
x
x
x
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Control Interventions

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

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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

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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

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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

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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

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• 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

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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