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Infection Prevention & Control of
Multidrug-resistant Organisms
in Ambulatory Surgical Centers
Jane Harper, RN, MS, CIC
Lindsey Lesher, MPH
Minnesota Department of Health
Acute Disease Investigation and Control Section
Objectives
• Describe multidrug-resistant organisms (MDRO)
• Describe MDRO surveillance trends in Minnesota
• Describe MDRO infection prevention and control
measures in ambulatory surgical centers
• Describe antibiotic resistance
Drug-resistant 'superbugs'
hit 35 states,
spread worldwide
By Steve Sternberg, USA TODAY Sept. 17, 2010
Bacteria that are able to survive every modern antibiotic are cropping up in
many U.S. hospitals and are spreading outside the USA, public health officials
say.
The bugs, reported by hospitals in more than 35 states, typically strike the critically
ill and are fatal in 30% to 60% of cases. Israeli doctors are battling an outbreak in
Tel Aviv that has been traced to a patient from northern New Jersey, says Neil
Fishman, director of infection control and epidemiology at the University of
Pennsylvania and president of the Society of Healthcare Epidemiologists.
The bacteria are equipped with a gene that enables them to
produce an enzyme that disables antibiotics. The enzyme is called
Klebsiella pneumoniae carbapenamase, or KPC. It disables
carbapenam antibiotics, last-ditch treatments for infections that don't
respond to other drugs.
Multi-drug Resistant Organisms
(MDRO)
• Bacteria that acquire the ability to resist treatment
against more than one antibiotic
• Infections caused by MDRO:
– More difficult to treat; require more toxic antibiotics
– Often result in poor patient outcomes
– Cost more
• MDRO are readily transmitted in healthcare settings
SSI: surgical site infection
CLABSI: central line-associated bloodstream infection
VAP: ventilator-associated pneumonia
CAUTI: catheter-associated urinary tract infection
Source: CDC
Staphylococcus aureus
• ~ 20% of humans are persistently colonized
(children > adults); ~ 60% are intermittently
colonized
• Most often spread via contaminated hands
Methicillin-Resistant S. aureus
(MRSA)
• Resistant to beta-lactam antibiotics
(all penicillins and cephalosporins)
• Identified based on antimicrobial
susceptibility testing
MRSA Clinical Spectrum
Severe / Invasive Infections
Skin Infections
Colonization
“Types” of MRSA
• Community–associated (CA-MRSA)
– Skin infections common
– No recent hospitalization, dialysis, surgery, LTCF residence
– Susceptible to most antibiotics except beta-lactams and
erythromycin
• Healthcare-associated (HA-MRSA)
– Causes nosocomial pneumonia, surgical wound, and bloodstream
infections
– Risk factors: hospitalization, LTCF resident, dialysis, surgery
– Resistant to many antimicrobials
MRSA Cases Reported to MDH, 2000-2009
4,000
56% CAMRSA
Total MRSA
CA-MRSA
Total No. of Cases
3,500
3,000
2,500
12% CAMRSA
56%
2,000
51%
41%
1,500
53%
34%
1,000
500
12%
12%
14%
18%
22%
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Carbapenem-Resistant
Enterobacteriaceae (CRE)
Carbapenems
• Class of antibiotics
• Mainstay of treatment targeting resistant Gramnegative bacilli
• Ertapenem, imipenem, meropenem, doripenem
Enterobacteriaceae
• Large family of Gram-negative bacteria
• Common species
–
–
–
–
Klebsiella pneumoniae
Escherichia coli
Enterobacter cloacae
Enterobacter aerogenes
Carbapenem-Resistant
Enterobacteriaceae (CRE)
• Resistant to ≥3 classes of antibiotics, including
carbapenems
•
Resistance mechanisms
–
Enzymes that inactivate carbapenems
• Klebsiella pneumoniae carbapenemase (KPC)
• New Delhi Metallo β-lactamase (NDM-1)
–
Located on chromosomes or plasmids (mobile genetic
elements)
CRE Cases Reported to MDH, 2011
What kinds of infections do CREs
cause?
• Urinary tract, intestinal or abdominal, respiratory
tract, and wound infections
• Most frequently isolated from urine, sputum, or blood
• Bloodstream infections are associated with higher
rates of death than infection at other sites
Patel JB. Presented at 107th ASM General Meeting, 2007
Agmon O. Presented at 8th Congress of IFIC. 2007
Who is at increased risk for infection
with CREs?
• Hospitalized patients with:
–
–
–
–
Co-morbid conditions
Frequent or prolonged hospitalization
Invasive devices
Antimicrobial exposure (vancomycin, fluoroquinolones,
penicillins, and extended-spectrum cephalosporins)
Esther T. Tan, et al. CID. Submitted
Clostridium difficile (C. diff)
C. difficile Bacteria
• Named due to difficulty to isolate in the lab (Latin
difficile = difficult)
• Spore-forming, anaerobic, gram-positive bacillus
• Fecal-oral transmission
– Hands of healthcare personnel
– Contaminated inanimate objects
• Two major reservoirs:
– Infected humans (symptomatic or colonized)
– Inanimate objects
CDC Fact Sheet, 2005
Simor ICHE, 2002
C. difficile
Infection
(CDI)
Facts
Hospital stays from C.
difficile infections tripled in
the last decade, posing a
patient safety threat
especially harmful to older
Americans.
Almost all C. difficile
infections are
connected to getting
medical care.
Hospitals following infection
control recommendations
lowered C. difficile infection
rates by 20% in less than 2
years.
CDC. http://www.cdc.gov/vitalsigns/hai/
Risk Factors for C. difficile Infection
•
•
•
•
•
•
•
•
•
Main modifiable
Antimicrobial exposure
risk factors
Acquisition of C. difficile
Advanced age
Underlying illness
Immunosuppression
Tube feeds
Gastric acid suppression
Use of nasogastric or gastrostomy feeding tubes
Use of proton-pump inhibitors
CDI and Antibiotic Use
– > 90% cases occur during or after antibiotic therapy
– All antibiotics implicated;
• Broad spectrum agents are more likely associated
Clinical Manifestations of CDI
Asymptomatic
colonization
Diarrheal
illness
Pseudomembranous
colitis
Toxic megacolon
Asymptomatic
colonization may
be protective
against CDI
•
Fever
•
Cramping abdominal pain
•
Increased frequency of
loose, watery, unformed
bowel movements not due to
another cause
•
Recent history of antibiotic
exposure
SHEA and IDSA Guidelines, 2007
New Epidemic Strain of C. difficile
BI/NAP/027
Increased Toxin
Production
Fluoroquinolone
Resistance
Severe Clinical
Disease
Severity of Clostridium difficile infection is increasing
MDH CDI Surveillance
• Population- & laboratory-based surveillance
– Four central MN counties: Benton, Stearns, Morrison, Todd
– Olmsted county
MDH CDI Surveillance, 2011
Percent
of total
cases
Median
age
(years)
Community-onset,
no healthcare exposure
63%
49
Nosocomial
(onset >3 days after hospital admit)
19%
79
Community-onset
with healthcare exposure
18%
57
CDI case category
Summary of MDRO Surveillance
• Infections caused by MDRO are increasing
• MDRO infections require more toxic, expensive
antibiotics and result in increased adverse drug
reactions
• MDRO threaten the effectiveness of existing
antimicrobials
• MDRO are transmissible in healthcare settings and
the community
Ambulatory Surgical Centers
• Increasing and more complex, invasive care provided in
ambulatory care facilities
• Procedures performed in ASC:
– 1996: 32 million
– 2006: > 53 million
• From 1996 to 2006:
– 273% increase in spinal cord injections (increase of 1.5
million)
– 200% more colonoscopies (increase of 4 million)
Data from the National Survey of Ambulatory Surgery
GAO. HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. 2012.
Increased Awareness of Infection
Prevention & Control Needs in ASCs
Government Accountability Office (GAO) Report
(2009)
“The increasing volume of procedures and evidence
of infection control lapses in ASCs create a compelling need
for current and nationally representative data on HAIs in
ASCs in order to reduce their risk…”
Infection Prevention & Control Strategies
•
•
•
•
•
Standard Precautions
Isolation Precautions
Hand hygiene
Injection safety
Cleaning and high-level disinfection/sterilization of
reusable medical equipment
Standard Precautions
• Basic level of infection control precautions for use in the care of
all patients
• Applies to:
– Blood and all body fluids, secretions and excretions
– Non-intact skin
– Mucous membranes
• Personal protective equipment as indicated by
patient/procedure/situation
• Hand hygiene - always!
• Respiratory hygiene / cough etiquette
Transmission-based Precautions
Standard Precautions +
– Contact
• Direct (skin to skin, fecal-oral) and indirect (environmental)
• Gloves, gown (if splashing, contamination is possible)
• E.g. MRSA, CRE
– Droplet
• Large droplets: respiratory secretions, coughing, sneezing
• Surgical mask within 3-6 feet of patient
• E.g. Pertussis, influenza
– Airborne
• Pathogens suspended in air as small particles
• N95, PAPR, negative pressure room
• E.g. Tuberculosis, varicella
Hand hygiene
• Perform hand hygiene:
– After touching blood, body fluids,
secretions, excretions, etc.
–
–
• whether or not gloves were worn
Immediately after removing gloves
Between patient contacts
• Antimicrobial soap and water / friction
• Alcohol-based hand rubs
Caveat: Organic material inactivates
alcohol, must wash to remove visible soil
Standard Precautions: Injection Safety
• Practices that prevent contamination during preparation and
administration of all parenteral medications
CDC 2007 Guideline for Isolation Precautions www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
18 Outbreaks of Viral Hepatitis Associated
with Unsafe Injection Practices in
Ambulatory Settings, 2001-2011
Healthcare Setting
# of Outbreaks
Pain management clinics
5
Endoscopy clinics
5
Alternative medicine clinics
3
Hematology-oncology clinics
2
• 2 common unsafe injection practices that resulted in BBP
transmission (both can transmit infections, even if the needle is
changed):
– Reuse of a syringe for multiple patients
– Accessing a medication vial used for multiple patients
Source: CDC
CDC One and Only Campaign
• Promote safe injection practices
• Provide information to clinicians in all types of healthcare
settings
Unsafe injection practices = never events
Injection safety training video www.oneandonlycampaign.org/videos/Default.aspx
CDC injection safety FAQs from providers www.cdc.gov/injectionsafety/
Cleaning and Disinfection/Sterilization:
Reusable Medical Equipment
• Reusable medical equipment must be appropriately
cleaned and disinfected / sterilized prior to each use
– Glucometers, other point of use devices
– Endoscopes
– Surgical instruments
• Assign responsibilities and ensure annual competency
training and education
• Use appropriate PPE when handling/reprocessing
contaminated equipment
Endoscope Reprocessing Breaches
Reported to MDH, 2010-2011
No.
Healthcare facility type
Ambulatory surgical center
Clinic
Hospital
1
1
5
Breaches that resulted in patient notification
4
Number of patients affected
Cause of breach
Lack of communication between reprocessing departments
within facility
Endoscope owned by physician; facility did not take responsibility
for regular maintenance and staff training
Reprocessing of single use device following incorrect instructions
provided by vendor representative
Failure to follow manufacturer instructions resulted in use of
incorrect AER connector
6 - 2,600
Piece of cleaning brush dislodged into patient's colon procedure
Use of improper AER connector due to incorrect manufacturer
instructions
Unknown
1
1
1
1
1
1
1
MDH Poster
Key Endoscope
Reprocessing Steps
www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/scope/
Antimicrobial Stewardship Goals
Optimize
Patient Safety
Reduce
Resistance
Decrease or
Control
Costs
Antimicrobial Stewardship
Strategies
Right drug/dose/duration
Obtain cultures/avoid empiric prescribing if
possible
Adjust empiric prescribing/stop antibiotic
based on lab results
Antimicrobial Stewardship Programs
• Provide the infrastructure to preserve antimicrobials
• Promote patient safety
• Can be implemented in any healthcare setting – from
the smallest to the largest
• CDC: Get Smart About Antibiotics in Healthcare
http://www.cdc.gov/getsmart/healthcare/?s_cid=dhqp_002
Minnesota Guide to a Comprehensive
Antimicrobial Stewardship Program
New!
www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/index.html
Resources Available From the
MDH Website
http://www.health.state.mn.us/
Two components:
• SAFE =
Infrastructure to
support SSI
Prevention
Strategies
• SSI Prevention
Strategies =
“CUTS”
www.health.state.mn.us/divs/idepc/dtopics/hai/ssi/toolkit/index.html
SAFE CUTS
• SSI Prevention Team
– Champion, inter-disciplinary team
• Access to Information
– Audit prevention steps (e.g., a pre-, intra-, post-procedure checklist
– Measure outcomes (National Healthcare Safety Network [NHSN])
• Facility Expectations
– Process for speaking up and “stopping the line”
– Communicate expectations to all providers: pre-op evaluation for
infections; postpone elective surgery until infection resolved
• Education
– Clinicians and staff
– Patients (pre-op, post-op)
SAFE CUTS (cont.)
• Cleaning surgical equipment/environment
– Appropriate use of immediate use sterilization
• Undergoing surgery
– Pre-op: antibiotics, pre-warming, blood glucose, skin prep
– During: Keep OR door closed, maintain normothermia
– Post-op: Normothermia, blood glucose, patient /family education
• Team Accountability/Communication
– pre-op briefing, surgical checklist to track SSI prevention measures
• Staff
– Expectations: hand hygiene, illness, surgical attire
SAFE From CDI
www.health.state.mn.us/divs/idepc/diseases/cdiff/toolkit/index.html
MRSA Patient Education
www.health.state.mn.us/divs/idepc/diseases/mrsa/index.html
CDC Resources
• CDC Management of Multidrug-Resistant Organisms In
Healthcare Settings, 2006 www.cdc.gov/hicpac/mdro/mdro_0.html
• CDC, Guide to Infection Prevention for Outpatient Settings:
Minimum Expectations for Safe Care and the Infection
Prevention Checklist for Outpatient Settings: Minimum
Expectations for Safe Care
www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html
• See CDC, Basic Infection Control and Prevention Plan for
Outpatient Oncology Settings, accessed March 1, 2012,
www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan2011/index.html
• Get Smart: Know When Antibiotics Work
www.cdc.gov/getsmart/
Summary
• MDRO are a growing challenge in all areas of healthcare
• Early identification of MDRO and implementation of infection
prevention and control measures is effective in limiting transmission
• Antimicrobial stewardship is a critical component of MDRO prevention
• Patient education is an important MDRO prevention measure in
ambulatory care
• Compliance with infection prevention measures is essential
Questions?
Minnesota Department of Health website
www.health.state.mn.us/divs/idepc/diseases/mrsa/index.html
MDH Acute Disease Investigation and Control
651-201-5414 or
toll-free 1-877-676-5414
Thank You!