Management of MDRO

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Multi Drug Resistant Organism (MDRO)
Dr Sanjay Kumar Gupta MD,DHM Infection Control
Department ,AGH
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Contents

• 1. Background
• 2. Definition
• 3. Epidemiology of MDRO
• 4. Various risk factors for MDRO
• 5. Management of MDRO
• 6.Prevention and Control of MDRO

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Introduction

• Multidrug-resistant organisms (MDROs), including
  methicillin-resistant Staphylococcus
  aureus (MRSA), Vancomycin-resistant enterococci
  (VRE) and certain gram-negative bacilli (GNB)
  have important infection control implications. 

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MDRO Definition.

• For epidemiologic purposes, MDROs are defined as
  microorganisms, predominantly bacteria, that are
  resistant to one or more classes of antimicrobial
  agents.

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The Simplest Approach
The Not Quite As Simple But Now The Closest Thing
We Have to Universally Accepted Approach
Multi drug - resistant
Resistant to gt 1 drug
Non-susceptible to one or more classes of drugs
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XDR and PDR
Extensively drug resistant
Non-susceptible to at least 1 drug in all but two
or fewer classes
Pan drug resistant
Non-susceptible to all agents in all classes
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MDRO(multidrug resistant organisms

• 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.

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MDRO(multidrug resistant organisms

• 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

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Methicillin-Resistant Staphylococcus
aureus(MRSA) Among Intensive Care Unit
Patients,1995-2004
Source National Nosocomial Infections
Surveillance (NNIS) System
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Vancomycin-Resistant Enterococci (VRE) Among
Intensive Care Unit Patients,1995-2004
Vancomycin- Resistant Enterococci (VRE) among
Intensive Care Unit Patients,1995-2004
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3rd Generation Cephalosporin-Resistant Klebsiella
pneumoniae Among Intensive Care Unit Patients,
1995-2004
Source National Nosocomial Infections
Surveillance (NNIS) System
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Fluoroquinolone-Resistant Pseudomonas aeruginosa
Among Intensive Care Unit Patients, 1995-2004
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Various risk factors for MDRO

• The presence of vulnerable patients, such as
  those with compromised immunity from underlying
  medical or surgical conditions, those who have
  indwelling devices including endotracheal tubes,
  vascular catheters or urinary catheters.
• ? The reservoir of infected or colonized patients
• ? The selective pressure exerted by antimicrobial
  use
• ? The effectiveness of local infection prevention
  and control measures.

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Cont.

• There is ample epidemiologic evidence to suggest
  that MDROs are carried from one person to another
  via the hands of HCP (6).
• Hands are easily contaminated during the process
  of care-giving or from contact with environmental
  surfaces in close proximity to the patient(7).

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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.
• Additional factors that can facilitate
  transmission, include chronic sinusitis , upper
  respiratory infection , and dermatitis .

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Key Prevention Strategies
Clinicians hold the solution!

" 1) Prevent infection " 2)
Diagnose and treat infection effectively 3)
Use antimicrobials wisely 4) Prevent
transmission
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Selection for antimicrobial-resistant Strains
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Emergence of Antimicrobial Resistance
Campaign to Prevent Antimicrobial Resistance in
Healthcare Settings
Susceptible Bacteria
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Antimicrobial Resistance Key Prevention
Strategies
Pathogen
Susceptible pathogen
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12 Steps to Prevent Antimicrobial Resistance
Hospitalized Adults
Use Antimicrobials Wisely

• 5. Practice antimicrobial control
• 6. Use local data
• 7. Treat infection, not contamination
• 8. Treat infection, not colonization
• 9. Know when to say no to Vancomycin
• 10. Stop treatment when infection is cured or
  unlikely
• 11. Isolate the pathogen
• 12. Break the chain of
• contagion

• 1. Vaccinate
• 2. Get the catheters out
• 3. Target the pathogen
• 4. Access the experts

Prevent Infection
Diagnose and Treat Infection Effectively
Prevent Transmission
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Inappropriate Antimicrobial Therapy Prevalence
among Intensive Care Patients
Inappropriate Antimicrobial Therapy (n 655
ICU patients with infection
45.2
34.3
Community-onset infection Hospital-onset
infection Hospital-onset infection after
initial community-onset infection
inappropriate
17.1
Patient Group
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Other MDRO Prevention Strategies

• Enhanced infection control precautions may
  include
• Consider assigning dedicated nursing and
  ancillary staff to the care of patients with the
  MDRO.
• Education of all staff, including cleaning staff,
  should be intensified.

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Cont.

• Use of novel decontamination techniques, such as
  hydrogen peroxide vapour.
• This has been used successfully in the
  environmental management of Clostridium difficile
  and MRSA outbreaks.

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MDRO bundle

• Active surveillance
• Antimicrobial management including antimicrobial
  stewardship programme
• Practice of isolation precaution such as contact
  precaution
• Hand hygiene
• Environmental hygiene
• Antiseptic body bath by 4 chlorhexidine

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MDRO Bundle Check list
Appropriate Hand Hygiene Practice Personal protective equipments   Appropriate Hand Hygiene Practice Personal protective equipments   Chlorhexidine (4) body bath once daily Chlorhexidine (4) body bath once daily Single room or cohorting the patient with similar condition done Single room or cohorting the patient with similar condition done Dedicated non critical medical items used Dedicated non critical medical items used Place the contact isolation sign board outside the patient room Place the contact isolation sign board outside the patient room Appropriate antimicrobial therapy initiated Appropriate antimicrobial therapy initiated Appropriate antimicrobial therapy initiated Patient and visitor education done Patient and visitor education done Signature of Assigned Nurse on Duty
YES NO YES NO YES NO YES NO YES NO NO YES NO YES NO  
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