Infection Prevention & Control of Multidrug-resistant Organismsin Ambulatory Surgical Centers

Jane Harper, RN, MS, CIC

Lindsey Lesher, MPHMinnesota 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, 2010Bacteria 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 infectionCLABSI: central line-associated bloodstream infectionVAP: ventilator-associated pneumoniaCAUTI: 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

Colonization

Skin Infections

Severe / Invasive Infections

“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

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Total MRSA

CA-MRSA

12% 12% 14%18%

22%

34%

41%

Year

To

tal N

o. o

f C

as

es

12% CAMRSA

56% CAMRSA

51%53%

56%

Carbapenem-Resistant Enterobacteriaceae (CRE)

Carbapenems

• Class of antibiotics

• Mainstay of treatment targeting resistant Gram-negative 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, 2007Agmon 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

Almost all C. difficile infections are connected to getting medical care.

Hospital stays from C. difficile infections tripled in the last decade, posing a patient safety threat especially harmful to older Americans.

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

• Antimicrobial exposure• 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

Main modifiable risk factors

CDI and Antibiotic Use

– > 90% cases occur during or after antibiotic therapy

– All antibiotics implicated; • Broad spectrum agents are more likely associated

Asymptomatic colonization may be protective against CDI

Clinical Manifestations of CDI

• Fever

• Cramping abdominal pain

• Increased frequency of loose, watery, unformed bowel movements not due to another cause

• Recent history of antibiotic exposure

Asymptomatic colonization

Diarrheal illness

Pseudomembranous colitis

Toxic megacolon

SHEA and IDSA Guidelines, 2007

Severity of Clostridium difficile infection is increasing

BI/NAP/027

New Epidemic Strain of C. difficile

Increased Toxin Production

Fluoroquinolone Resistance

Severe Clinical Disease

MDH CDI Surveillance

• Population- & laboratory-based surveillance– Four central MN counties: Benton, Stearns, Morrison, Todd– Olmsted county

CDI case category

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

MDH CDI Surveillance, 2011

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)

GAO. HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. 2012.

Data from the National Survey of Ambulatory Surgery

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…”

Increased Awareness of Infection Prevention & Control Needs in ASCs

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

• 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

Healthcare Setting # of Outbreaks

Pain management clinics 5

Endoscopy clinics 5

Alternative medicine clinics 3

Hematology-oncology clinics 2

CDC One and Only Campaign• Promote safe injection practices

• Provide information to clinicians in all types of healthcare settings

Injection safety training video www.oneandonlycampaign.org/videos/Default.aspx

CDC injection safety FAQs from providers www.cdc.gov/injectionsafety/

Unsafe injection practices = never events

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 1 Clinic 1 Hospital 5

Cause of breach Lack of communication between reprocessing departments within facility 1 Endoscope owned by physician; facility did not take responsibility for regular maintenance and staff training 1 Reprocessing of single use device following incorrect instructions provided by vendor representative 1 Failure to follow manufacturer instructions resulted in use of incorrect AER connector 1

Piece of cleaning brush dislodged into patient's colon procedure 1 Use of improper AER connector due to incorrect manufacturer instructions 1 Unknown 1

Breaches that resulted in patient notification 4

Number of patients affected 6 - 2,600

MDH Poster Key Endoscope Reprocessing Steps

www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/scope/

Antimicrobial Stewardship Goals

Antimicrobial StewardshipStrategies

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 Healthcarehttp://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

www.health.state.mn.us/divs/idepc/diseases/cdiff/toolkit/index.html

SAFE From CDI

www.health.state.mn.us/divs/idepc/diseases/mrsa/index.html

MRSA Patient Education

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-plan-2011/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 Control651-201-5414 or

toll-free 1-877-676-5414

Thank You!