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Kermanjani
1. Guide to the Elimination of
Multidrug-resistant Organisms
(MDRO) Transmission in
Healthcare Settings
Ali Kermanjani
MSc, Ph.D
Faculty of Medicine, Iran University of Medical Sciences
Director, Research & Development (R&D) at Behban Pharmed Co.
2.
3. Antibiotics
• Antibiotic is defined by the World Health Organization
(WHO) as “a synonym for antibacterials used to treat
bacterial infections in both people and animals.”
4. The history of antibiotics
Penicillin production in the beginning:
glass flasks and milk churns used for making early forms of penicillin
The United States to produce 2.3 million doses in time for the invasion of Normandy
in the spring of 1944.
8. “It is not difficult to make microbes resistant to
penicillin… “
“The time may come when penicillin can be bought by
anyone in the shops “
Alexander Fleming's Nobel Lecture, 1945
9. Barrier to the development of new
antibiotics
• Short marketing life of the product because of resistance
• Difficult R&D
• long term research and translation
• Adverse reactions
• Expense for health care
12. Clinical deployment of new antibiotics (blue bars) has quickly been followed by the
evolution of bacteria able to resist their effects (red). During the golden age of discovery,
150 types of antibiotics were developed. Since then, the spread of resistance has greatly
outpaced the rate of drug development. The Infectious Disease Society of America estimates
that 70% of hospital-acquired infections in the United States are now resistant to one or more
antibiotics.
14. Microorganisms
• Multidrug Resistant (MDR):
Resistant in at least one agent in ≥3 antimicrobial categories
• Extensively Drug Resistant (XDR):
All classes of antibiotics except 1 or 2 (usually colistin ± tigecycline)
• “Pandrug Resistant (PDR):
All classes of antibiotics, since in the Greek language the prefix “pan-” means “all” or “whole”
15. Regarding level of concerns bacteria are
prioritized into one of three categories
• Urgent threats
These are high-consequence antibiotic-resistant threats.
1. Clostridium difficile
2. Carbapenem-resistant Enterobacteriaceae
3. Drug-resistant Neisseria gonorrhoeae
• Concerning threats
These are bacteria for which the threat of antibiotic resistance is low,
and/or there are multiple therapeutic options for resistant infections.
1. Vancomycin-resistant Staphylococcus aureus (VRSA)
2. Erythromycin-resistant Group A Streptococcus
3. Clindamycin-resistant Group B Streptococcus
• Serious threats
• These are significant antibiotic-resistant threats.
1. Multidrug-resistant Acinetobacter
2. Drug-resistant Campylobacter
3. Fluconazole-resistant Candida (a fungus)
4. Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)
5. Vancomycin-resistant Enterococcus (VRE)
6. Multidrug-resistant Pseudomonas aeruginosa
7. Drug-resistant non-typhoidal Salmonella
8. Drug-resistant Salmonella Typhi
9. Drug-resistant Shigella
10. Methicillin-resistant Staphylococcus aureus (MRSA)
11. Drug-resistant Streptococcus pneumoniae
12. Drug-resistant tuberculosis
16. • Bad Bugs, No Drugs: No ESKAPE
– Enterococcus faecium (E), Staphylococcus
aureus (S), Klebsiella pneumoniae (K),
Acinetobacter baumannii (A), Pseudomonas
aeruginosa (P), and Enterobacter spp. (E)
• Enterococcus
• S. aureus
• Klebsiella spp.
• Acinetobacter
• P. aeruginosa
• Enterobacter spp.
17. Factors facilitating the spread of MDRO
(Acinetobacter baumannii)
• Increased length of hospital stay
• Mechanical ventilation
• exposure to antimicrobial agents
• exposure to an intensive care unit (ICU)
• Exposure to patients colonized or infected with A. baumannii
• recent surgery
• Environmental contamination
• Understaffing
• Poor adherence of staff to hand hygiene
18. Factors Promoting Transmission of
Acinetobacter in the ICU
• Long survival time on inanimate surfaces
• In vitro survival time 329 days
(Wagenvoort JHT, Joosten EJAJ. J Hosp Infect 2002;52:226-229)
• 11 days survival on Formica, 12 days on stainless steel
(Webster C et al. Infect Control Hosp Epidemiol 2000;21:246)
• Up to 4 months on dry surfaces
(Wendt C et al. J Clin Microbiol 1997;35:1394-1397)
• Extensive environmental contamination
• Highly antibiotic resistant
• High proportion of colonized patients
• Frequent contamination of the hands of healthcare workers
18
21. Fact: Catheters and other invasive devices are the # 1 exogenous cause of
hospital-onset infections.
Actions:
use catheters only when essential
use the correct catheter
use proper insertion & catheter-care protocols
remove catheters when not essential
Prevent Infection
Get the catheters out
22. Biofilm on Intravenous Catheter Connecter 24 hours after
Insertion
Scanning
Electron Micrograph
23. Use Antimicrobials Wisely
: Treat infection, not contamination
Fact: A major cause of antimicrobial overuse is “treatment” of contaminated
cultures.
Actions:
use proper antisepsis for blood & other cultures
culture the blood, not the skin or catheter hub
use proper methods to obtain & process all cultures
24. Co-humans ( HCW ) are great carriers of Infection
• Acinetobacter causes colonization more
often than infection; this means that it
lives in or on the body without causing
illness (e.g., the skin of a healthcare
worker). People who are colonized can
become carriers who spread the bacteria
to other people, usually without realizing
it.
25. Use Antimicrobials Wisely
Stop antimicrobial treatment
Fact: Failure to stop unnecessary antimicrobial treatment
contributes to overuse and resistance.
Actions:
when infection is cured
when cultures are negative and infection is unlikely
when infection is not diagnosed
26. Fact: Healthcare personnel can spread
antimicrobial-resistant pathogens
from patient-to-patient.
Prevent Transmission
Break the chain
of contagion
27. Vectors for transmission of
infection
Asymptomatic patient
Healthy carrier
Healthy
patient
Symptomatic
patient
Caregivers/Nurses
Environnement
28. Prevent Transmission
Isolate the pathogen
Fact: Patient-to-patient spread of pathogens can be
prevented.
Actions:
use standard infection control precautions
contain infectious body fluids
(use approved airborne/droplet/contact isolation precautions)
when in doubt, consult infection control experts
29. Contact Precautions
• Patient transport:
• Patient: Patient wears clean gown.
Cover any open wounds.
Cover patient with clean sheet prior to
transport.
• HCW: Wear Personal protective equipment
(PPE) when touching patient.
(HealthcareRemove and dispose of PPE and perform
hand hygiene prior to transporting patient.
• Don clean PPE to handle patient at transport
destination 29
30. Patient Placement and Contact Precautions
• Cohorted in 3 way:
1. patient with MDRO should be placed in a private room .
2. patient should be cohorted with another patient infected with the same organism
3. patient should be placed in a room with another patient who is considered low risk for acquisition of
MDRO
• Basics of Contact Precautions
• Mouth, Nose, Eye Protection
• Considerations When Patients on Contact Precautions Leave Their Rooms
31. Improved Patient Outcomes associated with Proper
Hand Hygiene
Ignaz Philipp
Semmelweis
(1818-65)
Chlorinated lime hand antisepsis
32. Major components of a hand hygiene
program
• Implement a hand hygiene program including all levels
of healthcare providers
• Educate visitors
• Wear gloves for all contact with blood, body fluids and
moist body surfaces
• Always perform hand hygiene after removing gloves
• Perform hand hygiene before and after contact with a
patient
• Perform hand hygiene before and after contact with the
patient’s environment
• Monitor compliance with hand hygiene for all levels of staff
• Provide feedback of compliance rates based on observations
or volume of hand hygiene products used
• Hold healthcare care providers and administrators
accountable appropriate hand hygiene practices
• Use of alcohol-based hand sanitizer
• Perform hand hygiene in 5 moments
• Monitor compliance with hand hygiene for all levels of staff
• Artificial Fingernails
• Jewelry
32
34. What are Biofilms?
• Biofilms are collections of
microorganisms (bacteria, yeasts,
and protozoa) that form on a hard
surface
• Some examples of biofilms are the
plaque that forms on teeth and the
slime that forms on surfaces in
watery areas
35. Formation of conditioning layer
Planktonic bacterial cell attatchment
Detachment ( seeding dispersal )
Bacterial growth and Biofilm Expansion
Steps in Biofilm formation
36. Environmental Cleaning
• Monitoring of staff
• Education
• It is important to stress that high-touch areas
undergo effective cleaning and disinfection
• Ventilators, suctioning equipment, mattresses,
sinks and portable radiology equipment are
some of the more common sources that remain
colonized for extended periods
36
37. Environmental Cleaning
• Properly trained environmental services staff
• the use of approved disinfectants/ germicides
• effective protocols and/or checklists
• Environmental cleaning should be done daily or
more frequently, depending on the situation
• Perform environmental cultures
• Terminal cleaning
• Hypochlorite solutions
• VHP technology (vaporized
hydrogen peroxide)
37
38. Outbreak Situation—Intensify Environmental
Cleaning Efforts
Reinforce environmental staff cleaning procedures.
Consider placing dedicated cleaning staff to outbreak areas.
Monitor cleaning performance by environmental staff using observation
and/or use of fluorescent staining.
Ensure consistent cleaning and disinfection of high-touch areas (checklists
can be used to guarantee consistency) .
Perform environmental cultures if the environment is implicated in
transmission of the MDR Ab.
Terminal Cleaning
39. Is resistance to disinfectants an issue?
• Wisplinghoff et al. recently compared the in vitro activities of various disinfectants,
such as propanol, mecetronium ethylsulfate, polyvinylpyrrolidone-iodine, triclosan,
and chlorhexidine, against sporadic and epidemic A. baumannii strains by using a
broth macrodilution method
• All disinfectants inhibited growth of all A. baumannii isolates when concentrations
and contact times recommended by the respective manufacturer were used.
• However, with most of the disinfectants tested, a substantial number of viable
bacteria remained if contact times were <30 s or if diluted agents were used, as may
occur in day-to-day clinical practice.
• Minor deviations from the recommended procedures leading to decreased
concentrations or exposure times may play a role in nosocomial cross-transmission
40. Preventing Acinetobacter Transmission in the ICU
• Hand cultures
• Surveillance cultures
• Environmental cultures following terminal disinfection to document cleaning
efficacy
• Cohorting
• Ask laboratory to save all isolates for molecular typing
• Healthcare worker education
40
41. Continues to be a important Pathogen
• Although commonly found on the skin of healthy humans, Acinetobacter
plays the role of an opportunistic pathogen in the critically ill patient
• High level of antibiotic resistance makes it well suited as a pathogen in
areas with high use of antibiotics (e.g., ICU setting)
• Control requires good hand hygiene, barrier precautions &
environmental decontamination
• Alcohol-based products containing chlorhexidine should be considered the
hand hygiene agents of choice 41
42. Conclusions
• MDRO are growing in prevalence in multiple geographic locales
• Occur in a variety of healthcare associated settings
• Even in the community
• Antimicrobial stewardship is here to stay
• Novel methods to control spread of MDROs are attractive but
not clearly effective/cost-effective
43. Conclusions (2)
• Technologic advances regarding environmental hygiene are
helpful
• Technology and protocols alone will not prevent infections –
need compliance with basic process components
• No single process is completely effective in limiting the spread
of MDRO
• Regional approaches to controlling the spread of antimicrobial
resistance are needed
