APIC Annual Conference – June 10, 2009

16 Pages·2009·1.02 MB·English

MDROs
It’s not just about MRSA
Titus L. Daniels, MD MPH
Assistant Professor of Medicine (Infectious Diseases) –VUSM
Associate Hospital Epidemiologist –Vanderbilt Medical Center
Hospital Epidemiologist –Williamson Medical Center
APIC Annual Conference –June 10, 2009
Disclosers
Acknowledgements
•Vicki Brinsko •Jan Szychowski
•Amy Dziewior •Kathie Wilkerson
•Tracy Hann •Vicki Sweeney
•Lorrie Ingram
MDROs
•MRSA= Methicillin –resistant 
Staphylococcus aureus
•VRE= Vancomycin –resistant 
enterococcus
•CDAD= C. difficile associated diarrhea
•MDRGN= Multi‐drug resistant Gram‐
negatives
An example
77 y/o male 
Hospitalized much of the prior 90 days
Slowly recovering
Now extubated
Sitting up, working with physical therapy
Eating well, gaining weight
Family reporting “best he’s looked 
in a year”
Plans for rehab transfer in 2‐3 
days
Then…
Diarrhea develops
Intubated again as sepsis develops
C. difficile test is positive
Toxic megacolon develops
Patients dies 48 hours later
Why did this happen?
3 days before diarrhea started…
–Patient in adjacent room diagnosed 
with C. difficile diarrhea
–Staff repeatedly observed not 
adhering to hand hygiene or isolation 
practices
–Shared staff documented
CDAD
•Clostridium difficile
–Gram positive spore forming organism
•Known pathogen since 1978
•Many consider a strict iatrogenic 
pathogen
•Previously easily recognized and 
treated
“New” strain
•Increased toxin production –as much as 
20x
•Toxin appears more virulent
•Toxin is less likely to be “turned”off
•Resistant to fluoroquinolone antibiotics
•Organism associated with 
hypersporulation
Rates of CDAD – United States
Diagnosis
•Relatively straight‐forward
–Use of enzyme based tests most common
–Detection of toxinis important
–False negative results occur up to 20%
•Clinical suspicion and probabilities 
should not be swayed substantially by 
negative testing
Treatment
•Optimal treatment options are evolving
•Most experts recommend:
–VancomycSin orTally O+ metPronidazole IV for 
severe disease
–Metronidazole for mild‐moderate disease
•Oralo ist mhoesrt  eaffnecttiivme icrobials
•IV is an alternative
•Use of probiotics?
VRE
•Gram positive bacteria
•Related to the Streptococci
•Long considered of “low”
virulence
•Widely recognized cause of 
healthcare‐associated infections
VRE Epidemiology
Does VRE matter?
Chance of death with VRE is 
2.5 times greater
than with non‐VRE
True MDROs
Gram‐negative bacteria
–Klebsiella pneumoniae
–Pseudomonas aeruginosa
–Acinetobacter baumannii
Troops in Iraq Bring Resistant Bacteria Home
Sciences and Medicine
Military Chases Mystery Infection
Drug resistant bacteria 
≠
NEW
A quick primer
Resistance among “key”pathogens
Am J Infect Control 2004;32(8):470–485.
Imipenem resistance
Intermediate resistance Fully resistant
The Surveillance Network. >250 hospitals in US; >2000 reported infections annually
Livermore. Ann Med 2003;35:226-234
Resistance in U.S. ICUs
• 1994 ‐2004
• > 300 intensive care units
• 8537 isolates 
–~ 3600 resistant to at least one principal 
agent
• Fluoroquinolone resistance: 49.5 ‐73%
• β‐lactam resistance: 39 ‐66%
• Aminoglycoside resistance: 19 ‐30.5%
• Carbapenem resistance: 9 ‐38.5%
Carey, et al. Abstract K-1495. 46th ICAAC; Sept. 2006
Even more concerning…
•Emergence of carbapenemases
–KPC = Klebsiella pneumoniae
carbapenemase
–CRE = carbapenem resistant 
Enterobacteriacae
Deaths associated with bacteria
BSIs per  % Total BSI  % ICU BSI  % Non‐ICU BSI % Total Crude % ICU Crude  % Non‐ICU 
Pathogen 10,000 adm n=20,978 n=10,515 n=10,442 Mortality Mortality Mortality
CNS 15.8 31.3 35.9 26.6 20.7 25.7 13.8
S. a3ureu8s .7%1 0.3 Pse20.2udo16.m8 on23a.7 s a2e5.4rug3i4.n4 osa18.9
Enterococcus 4.8 9.4 9.8 9 33.9 43 24
Ps. 3aeru4gino.sa0  %2 .1 Aci4.3neto4.7bac3t.8er b38.a7 um47a.9 nni27i.6
Enterobacter 1.9 3.9 4.7 3.1 26.7 32.5 18
Kleb3siel3la .9%2 .4 En4t.8ero4cocc5u.5 s 27.6 37.4 20.3
E. coli 2.8 5.6 3.7 7.6 22.4 33.9 16.9
Serratia 0.9 1.7 2.1 1.3 27.4 33.9 17.1
A. baumannii 0.6 1.3 1.6 0.9 34.0 43.4 16.3
24,179 BSIs from SCOPE Project
Wisplinghoff, et al. Clin Infect Dis 2004;39:309-17
Another example…
22 y/o male 
75% burns from explosion
Hospitalized in burn unit 47 days
Fever develops
Cultures obtained
Empiric antibiotics started
Blood cultures return positive 
for A. baumannii
• Amikacin = R • Meropenem = R
• Gentamicin = R • Amp/Sulbactam = R
• Tobramycin = R • Pip/tazobactam = R
• Cefepime = R • Levofloxacin = R
• Imipenem = R • Tigecycline = R
Colistin = R
Now what do we do
Prevention
•Hand hygiene
•IsolaAtionn ptriamcticiecsrobial 
–Isolation based on syndromes or 
Stewardship
diagnoses
–When to stop
–Visitors 
•Environmental cleaning