22/09/2016 TALK OUTLINE WHAT ARE MDROS? The ABC of MDROs. 1. What are MDROs? 2. Why do MDROs matter in community care?

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1 RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn The ABC of MDROs Course Lecturer Safe Patient Care: Healthcare-associated Infection Prevention & Control for All: A Foundation Course Roisin Connolly Date 13 th September 2016 TALK OUTLINE 1. What are MDROs? 2. Why do MDROs matter in community care? 3. How big a problem do we have with MDROs? 4. What can we do about MDROs? WHAT ARE MDROS? Multi-Drug-Resistant Organisms i.e. bugs that antibiotics don t work against May also be referred to as antibiotic-resistant bacteria 1

2 ANTIBIOTIC-RESISTANT BACTERIA PATIENTS CAN BE COLONISED OR INFECTED WITH MDROS Colonisation: Bug is living on the patient but not causing them any harm Infection: Bug is living on the patient and making them sick 2

3 WHAT PUTS PATIENTS AT RISK OF MDROS? Previous antibiotic therapy Nursing home residents Multiple/ prolonged hospital admissions Extremes of age Chronic disease Immunosuppression Invasive devices HOW DO THESE BUGS GET AROUND? Patient-to-patient Via contaminated surfaces Via hands of patients Via hands of healthcare workers Via hands of visitors Hospital-to-hospital Direct patient transfer Patients attending more than one hospital Country-to-country MULTI-DRUG-RESISTANT ORGANISMS Some of the resistant organisms we are worried about: MRSA: Meticillin-resistant Staphylococcus aureus VRE: Vancomycin-resistant Enterococci ESBL: Extended-spectrum β-lactamase- producing Enterobacteriaceae CRE: Carbapenem- resistant Enterobacteriaceae 3

4 WHAT ARE THE BIG DIFFERENCES? 1.Where they live MRSA Lives on skin/ inside nose vs. VRE/ ESBL/ CRE Live in bowel Can decolonise No decolonisation WHAT ARE THE BIG DIFFERENCES? 2. The kinds of infections they cause MRSA causes cellulitis, wound infections, septic arthritis VRE doesn t often cause infections outside of hospitals ESBL- producing organisms and CRE cause mainly urinary tract infections and intra-abdominal infections o In some cases these can be very severe ( gram-negative sepsis ) and there is a high risk of death MRSA: METICILLIN-RESISTANT S. AUREUS Lives on skin and inside nose Many people may be colonised e.g. Healthcare workers, people who have been in hospital Only problematic when causes infection Cellulitis, wound infection, infected ulcers, line infections Bone/ joint infections 4

5 Family to sue over MRSA VRE: VANCOMYCIN-RESISTANT ENTEROCOCCI Live in the bowel Many people may be colonised Can t decolonise (bowel can never be sterilised) Don t usually cause infection outside hospitals Can survive for long periods on surfaces VRE IN THE PATIENT ENVIRONMENT 5

6 ESBL: EXTENDED-SPECTRUM BETA- LACTAMASE Enzymes carried by Gram-negative bowel organisms (e.g. E.coli, Klebsiella spp.) which make them resistant to: Cephalosporin antibiotics (e.g. Rocephin ) Sometimes co-amoxiclav ( Augmentin ) Sometimes piperacillin-tazobactam ( Tazocin ) ESBL-producing organisms live in the bowel Cause UTIs, intra-abdominal infections High prevalence among nursing home patients in Ireland CRE: CARBAPENEM-RESISTANT ENTEROBACTERIACEAE Gram-negative bowel organisms (e.g. E.coli, Klebsiella spp.) resistant to meropenem (our last-resort antibiotic) Live in the bowel Can t decolonise (bowel cannot be sterilised) Only problematic when they cause infection E.g. UTIs, intra-abdominal infection CRE: CARBAPENEM-RESISTANT ENTEROBACTERIACEAE More common in certain parts of the world e.g. Indian subcontinent, southern Europe Found in Ireland since 2009 and becoming more widespread A VERY BIG PROBLEM If a patient gets an infection with one of these, there may be no suitable antibiotic to treat them with and there is a high risk of death 6

7 TALK OUTLINE 1. What are MDROs? 2. Why do MDROs matter in community care? 3. How big a problem do we have with MDROs? 4. What can we do about MDROs? WHY DO MDRO S MATTER? If a patient gets an infection with one of these bacteria, they are very difficult to treat WHAT PUTS PATIENTS AT RISK OF MDROS? Previous antibiotic therapy Nursing home residents Multiple/ prolonged hospital admissions Extremes of age Chronic disease Immuno-suppression Invasive devices 7

8 WHY DO MDRO S MATTER IN LONG-TERM CARE? Patients in long-term care have all the risk factors High dependency/ incontinence means spread occurs easily between patients On healthcare workers hands Through contamination of surfaces Patients are often frail and prone to getting infections Infections with MDROs are difficult to treat Patients may initially get the wrong antibiotics e.g. if they are admitted to hospital and the hospital don t know they have an MDRO TALK OUTLINE 1. What are MDROs? 2. Why do MDROs matter in community care? 3. How big a problem do we have with MDROs? 4. What can we do about MDROs? CEPHALOSPORIN-RESISTANT E.COLI IN EUROPE ( ESBL -TYPE BUGS)

9 CARBAPENEM-RESISTANT KLEBSIELLA SPP. IN EUROPE ( CRE ) 2014 Downloaded from on 16/05/2016 SO HOW BIG A PROBLEM DO WE HAVE WITH MDROS? Ireland has the most VRE in Europe Problem with ESBL-producers and CRE is getting worse year on year And these are the ones that cause really serious infections What about in long-term care? We don t really know Because we don t check every resident BUT we know that a lot of nursing home patients who end up in hospital with infections have infections with MDROs, especially ESBLs So we think the rate of MDRO colonisation is probably a lot higher in LTCFs than in the community TALK OUTLINE 1. What are MDROs? 2. Why do MDROs matter in community care? 3. How big a problem do we have with MDROs? 4. What can we do about MDROs? 9

10 WHAT CAN WE DO ABOUT MDROS? Most residents in long-term care facilities who have MDROs are colonised rather than infected The priority is stopping the spread of the MDROs to other residents HOW CAN WE STOP THE SPREAD OF MDROS? 1. Knowledge is power Keep a record of which residents are colonised with MDROs If a resident is admitted to hospital, ensure the hospital is informed of their MDRO colonisation status HOW CAN WE STOP THE SPREAD OF MDROS? 2. Standard precautions Hand hygiene: Observe the WHO 5 Moments 10

11 HOW CAN WE STOP THE SPREAD OF MDROS? 2. Standard precautions Personal Protective Equipment (PPE): Use single-use disposable gloves and aprons when dealing with uncontrolled secretions, draining wounds, stool, stoma bags or tubes and pressure ulcers HOW CAN WE STOP THE SPREAD OF MDROS? 3. Single Rooms/ Contact Precautions Not usually appropriate but may be needed in some situations: Ill, highly-dependent residents Those who are incontinent or have uncontrolled secretions Residents with an MDRO infection rather than colonisation HOW CAN WE STOP THE SPREAD OF MDROS? 4. Reduce unnecessary antibiotic use Unnecessary antibiotic use causes emergence of MDROs Does the resident really need an antibiotic? Do they have a bacterial infection? e.g. Cloudy urine or a positive urine dipstick does not indicate a urinary tract infection and does not need antibiotic treatment in a patient who is otherwise well 11

12 National Guidelines Z/MicrobiologyAntimicrobialR esistance/infectioncontroland HAI/Guidelines/File,14478,en.pdf National Guidelines Z/MicrobiologyAntimicrobialResi stance/infectioncontrolandhai/g uidelines/file,12922,en.pdf SUMMARY Multi-drug-resistant organisms (MDROs) are antibioticresistant bacteria They are a big problem in long-term care facilities They can cause serious and life-threatening infections that can t be treated with the usual antibiotics Infection control precautions and careful antibiotic use are very important in stopping the spread of these resistant bugs 12

13 THANK YOU Any Questions? 13