Managing MDROs in LTCFs National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion Nimalie D. Stone, MD/MS Medical Epidemiologist for LTC GA LTC IC course Winter/Spring 2011
Apr 01, 2015
Managing MDROs in LTCFs
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
Nimalie D. Stone, MD/MSMedical Epidemiologist for LTC
GA LTC IC courseWinter/Spring 2011
Objectives
q Review basics about common bacteria which can develop antibiotic resistance in the healthcare setting
q Discuss mechanisms by which antibiotic resistance emerges and spreads
q Identify strategies for preventing MDRO transmission
Basics on Bacteria
• Bacteria have different characteristics that allow us to identify them in the lab• Growth patterns, structure of the cell
• We use these characteristics to develop antibiotics
Gram Stain Positive(purple)
Gram Stain Negative(pink/red)
Common types of Bacteria
Gram positive q Most are cocci, “round bacteria”
q Streptococcus, Staphylococcus, Enterococcus
q Clostridium difficile (C. diff) is a Gram positive rod
Gram negative q Most are baccili, “rod-shaped
bacteria”q Enterobacteriaceae: E coli,
Klebsiella, Enterobacter , Proteusq Pseudomonas
Normal Bacterial Carriage• People have bacteria
living in and on us all the time
• Some live on our skin, some in our nose and throats, others in our bowels
• Our bodies need these bacteria to help us
• Some digest food/nutrients, others block bad bugs
• These “colonizing” bacteria aren’t harmful• Only bacteria that invade our system and
cause illness need to be treated
Antibiotics 101
q Antibiotics are drugs that treat and kill bacteriaq They are grouped into classes based on their
structure and activity§ Narrow-spectrum target a few specific bacteria § Broad-spectrum can kill a wide variety of bacteria
q Infection prevention programs track certain “bug-drug” combinations for evidence that the bacteria is getting resistant§ Bacteria with resistance can cause patients to have
more severe, costly infections which are harder to treat
Antibiotic Classes
Penicillinsq Examples: Penicillin, amoxicillin, ampicillin, methicillinq Penicillins can be combined with a drug to help them
overcome certain bacterial resistance§ Amoxicillin + Clavulante = Augmentin; § Piperacillin + tazobactam = Zosyn
Cephalosporins (cousins to penicillins)q 1st generation (more gram positive activity):
Cephalexin, Cefazolinq 3rd/4th generation (more gram negative): Ceftriaxone,
Ceftazidime
Antibiotic Classes (cont)Carbapenemsq Examples: Imipenem, meropenem, ertapenemq Extremely broad-spectrum, among the most powerful
antibiotics we currently
Miscellaneous drugs with only gram positive activity: Vancomycin, linezolid, daptomycin
q Vancomycin is the primary treatment for Methicillin-resistant Staphylococcus aureus (MRSA)§ Oral vancomycin is ONLY used to treat C difficile;§ IV Vancomycin must be used to treat all other infections
q Enterococci that develop resistance to Vancomycin are called Vancomycin-resistant enterococci (VRE)
Antibiotic Classes (cont)Fluoroquinolonesq 1st generation (Ciprofloxacin) mostly gram neg
activity, often used for UTI treatmentq 2nd/3rd gen (Levofloxacin/Moxifloxacin) have broader
activity, can cover Streptococcus pneumoniae and other respiratory/sinus bacteria
Aminoglycosidesq Examples: Gentamicin, Tobramycin, Amikacinq Excellent gram negative drugs – especially for urinary tractq Aren’t used as much because can be toxic to the kidneys,
need to be monitored when used
Antibiotic Classes (cont)
Miscellaneous drugsq Trimethoprim/Sulfamethoxazole (Bactrim):
Considered by many to be narrow spectrum, but has Gram neg and Gram pos activity, used to treat UTIs, also good for MRSA skin infections
q Azithromycin (“Z-pack”): Also considered more narrow spectrum, good for respiratory/sinus infections
q Metronidazole (Flagyl): One of the main treatments for C. difficile infections
Mechanisms of antibiotic resistanceq Production of proteins that
destroy antibioticsq Beta-lactamasesq Carbapenemases
q Change their cell structure so antibiotics can’t bind and block their function
q Reduce their antibiotic exposureq Pump drugs outq Increase cell barriers to
keep drug outhttp://bioinfo.bact.wisc.edu/themicrobialworld/bactresanti.html
Snapshot of resistance patterns: Facility antibiograms
q A yearly summary of the common bacteria from facility cultures and their susceptibility patterns to antibiotics
q Allows you to see trends in resistance over timeq Ask your microbiology lab about it
Defining Multidrug-resistance
q Resistant to treatment by several antibiotics from unrelated classes
q Sometimes just one key drug resistance will define an important MDRO, for example, Methicillin-resistance in Staph aureus
q Sometimes bacteria acquire resistance to several classes, often seen in gram negative rodsq Cephalosporin-resistance is a big concern in bacteria
like E coli/Klebsiella which often cause UTIsq Pseudomonas will be resistant to fluoroquinolones,
penicillins, cephalosporins, and carbapenems
ABC’s of MDROs
Bacteria Abbrev.
Antibiotic Resistance
Staphylococcus aureus
MRSA Methicillin-resistant
Enterococcus (faecalis/faecium)
VRE Vancomycin-resistant
Enterobacteriaceae(E coli/Klebsiella, etc)
CRE (KPC)
Carbapenem-resistant
Pseudomonas/ Acinetobacter
MDR Many drug classes
Staphylococcus aureus
• Derived from the Greek word Staphyle: “Bunch of grapes” and aureus: “gold”
• Part of the normal colonizing bacteria on our skin and in the nose
• Though it colonizes many people, it may not cause infection unless the skin gets broken or the immune system gets weak
Methicillin-resistant Staphylococcus aureus (MRSA): An ongoing
problem• First emerged in the US healthcare setting in 1968– Outbreaks linked to transmission via healthcare
workers– Prevalence in nursing homes, 20-50%
• Community-acquired strains are adding to the burden of infection in the healthcare setting
• Increasing public and legislative pressure to address the transmission of MRSA in healthcare
Risk Factors for Healthcare- associated MRSA infections
• Previous hospitalization• Increased length of stay prior to onset of
infection• Surgery• Enteral feeding• Prior antibiotics• Invasive devices• History of MRSA colonization• Residence in a long-term care facility
1. Graffunder EM & Venezia RA. J Antimic Chemo 2002;49:999-1005 2. Oztoprak, N. et al. Am J Infec Cont. 2006; 34: 1-5 3. Wertheim et al. Lancet 2005; 5: 751-62 4. Bader, M. Inf Cont Hosp Epi. 2006; 27: 1219-1225
Clostridium difficile
• Gram positive rod which grows best without oxygen (anaerobic)
• C. diff has a special growth characteristic called “spores” • Hard outer shells in which
sleeping bacteria can survive in the environment for long periods
• Spores are shed in large numbers during the diarrhea caused by C diff infection (CDI)
Steps to C. diff Infection (CDI)
Acquisition of C. difficile
Antibiotic therapy
Changes normal colonic bacteria
C diff over grows and produces toxin
n More than half of healthcare associated CDI cases occur in long-term care facilities
n A significant number of individuals admitted to LTC are colonized with C difficilen Up to 20% acquire it while in nursing
homesn CDI is the most commonly identified cause
of acute diarrheal illness in the LTC population
CDI risk factors causing disease
Poutanen & Simor. CMAJ. 2004 171:51-8
Exposures and risk factors related to CDI in older adults
Simor. JAGS. 2010, e publ
C diff. prevention challenges
• Spores are not killed by alcohol hand rubs; the act rubbing your hands with soap under water removes the spores
• Spores are resistant to common cleaners and require bleach to be effectively killed
Managing a resident with C diff.• The goal of therapy for C diff infection is to
stop the symptoms of diarrhea, abdominal upset and fever
• Once the diarrhea has resolved, the resident is safe to move about the facility
• Residents can carry C.diff in their bowels (colonized) for months after their diarrhea resolves
• After being treating a resident for CDI, there is NO VALUE in sending multiple C diff stool studies to see if “the infection has cleared”• Often you’ll continue to get positive
results which prompt unnecessary additional treatment
Carbapenemase producing GNRs
• Carbapenemases are protein enzymes that break down all penicillins, cephalosporins and carbapenems
• There are different types of these enzymes some found in bugs like Acinetobacter and Pseudomonas ; others found in bugs like Klebsiella
• The genetic material also tends to carry resistance to other antibiotic classes like fluoroquinolones and aminoglycosides
• What’s really scary is that the resistance genes can be easily shared to other bacteria– Especially since we have lots of gram-negative bacteria
colonizing our bowels
Walsh, TR. Current Opin Infect Dis 2008;21:367-71
States reporting Carbapenem-Resistant Enterobacteriaceae (CRE)
www.cdc.gov/HAI/organisms/cre.html
Monitor your culture reports for Carbapenem-resistant
GNRsq Widely reported in the US and specifically Georgia
q Ask your referral hospitals if they have had problems
q Being aware of new resistance patterns in your residents will help you prevent spread
q Lab examined all the Acinetobacter cultured from people at 4 local hospitals over 5 years
q Classified as hospital-associated, NH-associated, or community-associated
q Wanted to see how antibiotic resistance emerged in this community
Case of an emerging MDRO….
Multidrug-resistance emerged quickly
q Over 5 year period, antibiotic resistance increased dramatically q In the last 2 years of the study pan-resistant bacteria emerged
q Culture sources: Respiratory secretions (56%); Wounds (22%); Urine (12%)
Sengstock DM, et al. Clin Infect Dis. 2010 50(12): 1611-1616
Healthcare facilities are the source of MDROs
Sengstock DM, et al. Clin Infect Dis. 2010 50(12): 1611-1616
q All the highly resistant bacteria were coming from patients in the hospital or those in the nursing homes – NOT from people living at home
MDROs in the healthcare settingDEVELOPMENT
q Antibiotic pressureq Most common predictor of antibiotic resistance is
prior antibiotic use
q Device utilization q Biofilm formation on central lines, urinary catheters,
etc.
SPREADq Patient to patient transmission via healthcare
workersq Environmental / equipment contaminationq Role of colonization pressure on acquisition
Resistance from antibiotic pressure
q At first most of the bacteria can be killed by the drug (green)
q But, once they are wiped out, the resistant bugs take over (red)
Antibiotic use drives resistance
Johnson et al. Am J. Med. 2008; 121: 876-84
Biofilm formation on device surfaces
q Biofilm: An collection of bacteria within a sticky film that forms a community on the surface of a device
http://www.ul.ie/elements/Issue7/Biofilm%20Information.htm
Biofilm on an indwelling catheter
Tenke, P et al. World J. Urol. 2006; 24: 13-20
Resistance develops within biofilms
q Bacteria within a biofilm are grow every differently from those floating around freelyq These changes in their growth make our antibiotics
less effectiveq Antibiotics can’t penetrate the biofilm to get to
the bacteria q This leads to much less drug available to treat the
bugsq Bacteria within the biofilm can talk to each
other and share the traits that allow some to be resistantq Over time more and more of them become resistant
as wellTenke, P et al. World J. Urol. 2006; 24: 13-20
Improved Patient Outcomes Associated with Hand Hygiene
Ignaz Philipp Semmelweis
(1818-1865)
Chlorinated Lime Hand Antisepsis
Adapted from CDC. Prevent Antimicrobial Resistance: A Campaign for Clinicians. April 2002.
Bacterial contamination of HCW hands prior to hand hygiene in a LTCF
Mody L, et al. InfectContHospEpi. 2003; 24: 165-71
q Gram negative
bacteria were the most common bugs cultured from hands of staff
q Most Gram neg. bacteria live in the bowls or colonize the urine!!!
Hand Hygiene
q Most effective and least costly means of preventing the transmission of MDROsqYet, compliance still ranges between ~30-60%
Alcohol-based hand rub improves compliance and
decontamination
Mody L, et al. InfectContHospEpi. 2003; 24: 165-71
Decreased MRSA infections associated with increased hand
hygiene compliance
Pittet, D et al.Lancet 2000;356:1307-12
The invisible reservoir of MDROs
• Image from Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
X marks the locations where VRE was isolated in this room
Slide courtesy of Teresa Fox, GA Div PH
Duration of environmental contamination by MDROs
Colonization pressure on risk of acquisition
q Colonization pressure: Presence of other MDRO carriers on a unit will increase the risk of MDRO acquisition to a non-carrier close by
q Studies have demonstrated the impact of colonization pressure on acquisition of MRSA, VRE and CDI
q Both asymptomatic carriers (colonized) and actively infected individuals can be a source for transmission (spread) on a unit
Williams VR et al. Am J Infect Control. 2009 Mar;37(2):106-10Bonten MJ et al. Arch Intern Med. 1998 May 25;158(10):1127-32.Dubberke ER et al. Arch Intern Med. 2007 May 28;167(10):1092-7
Colonization pressure: C.diff example
Unit AFewer patients with active CDI
=lower risk of acquiring CDI
Unit BMore patients with active CDI=higher risk of acquiring CDI
CDI pressure=1 × days in unit
CDI pressure=5 × days in unit
Dubberke ER, et al. Clin Infect Dis. 2007;45:1543-1549.Dubberke ER et al. Arch InternMed.2007;167(10):1092-7
Key MDRO Prevention Strategies
q Assessing hand hygiene practicesq Implementing Contact Precautionsq Recognizing previously colonized patientsq Rapidly reporting MDRO lab resultsq Strategically place residents based on MDRO
risk factors q Careful device utilizationq Antibiotic stewardshipq Inter-facility communication
Assessing Hand Hygiene
• Hand hygiene should be a cornerstone of prevention efforts
• As part of a hand hygiene intervention, consider:– Ensuring easy access to soap and
water/alcohol-based hand gels– Observation of practices - particularly
around high-risk situations (before and after contact with colonized or infected patients)
– Feedback – “Just in time” feedback if failure to perform hand hygiene observed
Implementing Contact Precautions
• Involves use of gown and gloves for patient care– Don equipment prior to room entry– Remove prior to room exit
• Selective roommate placement for MDRO colonized/infected individuals
• Observation of practices - particularly around high-risk situations
• Use of dedicated non-essential items may help decrease transmission due to contamination– Blood pressure cuffs; Stethoscopes; IV poles and pumps
Recognizing Prior Colonization
q Individuals can be colonized with MDROs for monthsq Being able to identify previously colonized or
infected individuals allows for application of appropriate interventions in a timely fashion
q Being an MDRO carrier should not prevent a resident from being admitted to a LTCF,q Knowledge allows us to plan for them to have the safest
careq For every resident carrying an MDRO that we know about,
there are probably 3 others we don’t know
Strategic placement of residents based on risk factors
• Base new roommate assignments on resident characteristics– Wounds, devices, current antibiotics,
incontinence are all risks for being an MDRO carrier or acquiring a new MDRO
– Try to avoid placing two high risk residents together
• Don’t necessarily change stable room assignments just because of a new culture result unless it now poses new risk– Roommates who’ve been together for a long
time have already had opportunity to share organisms in the past (even if you only learned about it recently)
Prompt Recognition of MDROs in Laboratory Reports
• Facilities should have a mechanism for rapidly communicating positive MDRO lab results to clinical area– Allows for rapid initiation of interventions on
newly identified MDRO carriers
• Consider implementing precautions while waiting for results from the lab if an MDRO is possible– For example, contact precautions for a resident
with diarrhea while waiting for results of a C diff stool study
Careful Device Utilization
• Know the population of residents with indwelling medical devices– May require focused infection surveillance
• Continually assess the ongoing need for devices– Develop a bladder protocol for urinary catheter removal– Resist the temptation to retain IV lines beyond the
duration of treatment “just in case”
• Ensure staff are comfortable and trained on handling/maintenance of medical devices
Antibiotic Stewardship
• Careful antibiotic use is a critical component in the control of MDROs
• Know the frequency/indications for antibiotic use by medical providers in your facility– Apply criteria to assess utilization in a standard way
• Develop standard protocols for communicating concerns and assessing residents who are suspected to have an infection between nursing and medical staff– Ensure documentation of signs/symptoms is complete
Case study on care transitionsq A LTC resident was transferred to a local
ED with worsening lower extremity swelling and shortness of breathq Resident’s history included coronary heart
disease, Diabetes with neuropathy, enlarged prostate
q Diagnosed with worsening heart failure admitted to ICU for cardiac monitoring and fluid management
q A urinary catheter was placed at the time of admission and a specimen was sent for UA/culture in ED. q Based on the UA, the patient was started on
antibiotics
Case study (continued)
q After treatment for heart failure and the positive urine culture, the resident was discharged backed to the LTC facility with the catheter in place.
q Prior to removing the urinary catheter a repeat culture was sent which grew VREq A second course of antibiotics was initiated
q Two weeks later the resident developed diarrhea and fever q Stool sample was positive C. Diff toxin test.
Issues raised by our case
q Is the practice of screening urine cultures on admission a valuable strategy?q What are the pros/cons
q Did the resident continue to need the urinary catheter once the CHF was managed?q How is resident functionality communicated at
time of transferq How are antibiotics used in both acute/LTC
facilities in this shared population?q Who is accountable for the complications of
antibiotic use?
Inter-facility Communication
• Mechanism for communicating MDRO carriage and other risk factors at time of transfer between facilities
• Critical components:– MDRO history of current infection or carriage– Device utilization– Current antibiotic treatments (indication/duration)– Bedside care issues (wounds, continence, etc)
Summary of Prevention Strategies
q Assessing hand hygiene practicesq Implementing Contact Precautionsq Recognizing previously colonized patientsq Rapidly reporting MDRO lab resultsq Strategically place residents based on MDRO
risk factors q Careful device utilizationq Antibiotic stewardshipq Inter-facility communication
q Describes the impact of regionally implemented infection control strategies to address VRE emerging in the Siouxland region of Iowa, Nebraska and S. Dakota
q Three annual point prevalence surveys (active surveillance) for VRE among patients/residents in participating acute/long-term care facilities
Story of Success…
Ostrowsky BE et al. New Eng J Med 2001 344: 1427-1433
IC practice guidelines for facilities
Ostrowsky BE et al. New Eng J Med 2001 344: 1427-1433
VRE prevalence decreased following prevention
interventionq 32 Facilities participated in 1997 and 1998 (4 acute/ 28 LTC) vs. 30 in1999 (4 acute/ 26 LTC)
q Overall 85%-89% of eligible patients/ residents cultured each year§ 52-59% in acute care§ 90-95% in LTC
Critical message about collaboration
Ostrowsky BE et al. New Eng J Med 2001 344: 1427-1433
Thank you!!
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
Email: [email protected] with questions/comments