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Recommendations for specific MDROs

The Oregon Public Health Division is working to improve patient safety by monitoring healthcare-associated infections (HAIs) and assisting health care facilities to identify and respond to multidrug-resistant organisms (MDROs).
 
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METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)
Staphylococcus aureus was the most common healthcare-associated infection (HAI) reported to the National Healthcare Safety Network (NHSN) during 2009–2010, accounting for 15.6% of all infections, 12.3% of central line-associated blood stream infections, and 30.4% of surgical site infections. MRSA caused 43.7–58.7% of S. aureus infections. Odds of having an infection can be 12.7 times greater in patients colonized with MRSA than those not colonized.
 
Oregon’s Active Bacterial Core Surveillance (ABCs) reviews invasive MRSA cases. Of 243 cases reported during 2011, 10% were healthcare-onset (HO), 54% were healthcare-associated, community-onset (HACO), and 35% were community-onset.
 
Most invasive healthcare-onset MRSA infections (21 of 25, 84%) manifested as bacteremia (68%) or endocarditis (16%). The good news: since 2004, HO invasive MRSA incidence has decreased 76% and HACO 45%, perhaps in part because of improved recognition and infection control.
 
Recommendations

Contact precautions are recommended in addition to standard precautions; add droplet if aerosol-generating procedure is anticipated. For ambulatory or home-care settings, use standard precautions.

There is no national recommendation for discontinuation of transmission-based precautions with MRSA. However, some facilities consider it when the patient is antibiotic-free for 6 weeks, and 3 surveillance cultures obtained at 3 different time points separated by at least 1 week are negative for MRSA. 

For more information: MRSA Diseases A-Z
 

VANCOMYCIN-RESISTANT ENTEROCOCCUS (VRE)
VRE is a public health concern because it can be transmitted by hands, surfaces, and fomites (e.g., respiratory, wound care medical equipment), and increase antibiotic needs, hospital stays, and patient morbidity and mortality. Vancomycin resistance is carried on Enterococcus sp. chromosomal or plasmid-based genes. E. faecium is more likely to carry the VAN gene conferring vancomycin resistance compared to E. faecalis (82.6% vs. 9.5%). Transfer of plasmid-based vancomycin resistance (VanA) has been documented in vancomycin-intermediate Staphylococcus aureus.
 
E. faecium and E. faecalis accounted for 4.1% and 6.8% of all healthcare-associated infections (HAI) reported to the National Healthcare Safety Network during 2009–2010. E. faecium and E. faecalis  were isolated most commonly in CLABSI (7.0% and 8.8%), followed by CAUTI (3.1% and 7.2%), SSI (2.5% and 5.9%), and rarely in VAP (0.3% and 0.5%).
 
Recommendations

Contact precautions are recommended in addition to standard precautions.

For more information: VRE Diseases A-Z
 

CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE)
CRE are of public health concern because plasmid-mediated antibiotic resistance can be transmitted to other gram-negative bacterium. CRE is primarily transmitted by contaminated hands and stool. CRE is primarily a nosocomial infection which accounts for 4% of bloodstream infections (NHSN 2012).
 
Recommendations

Contact precautions are recommended in addition to standard precautions; add droplet if aerosol-generating procedure is anticipated. For ambulatory or home-care settings, use standard precautions.

There is no national recommendation for discontinuation of transmission-based precautions, and should be determined by patient clinical status and most recent culture isolates. However, colonization may come and go over several months.

For more information: CRE Diseases A-Z
 

MULTIDRUG-RESISTANT ACINETOBACTER
Acinetobacter baumannii accounted for 1.8% of all healthcare-associated infections reported to the National Healthcare Safety Network (NHSN) during 2009–2010, but 6.6% of ventilator-associated pneumonias (VAPs), and 2.2% of central line-associated bloodstream infections (CLABSI). The majority was multidrug- or carbapenem-resistant: 63.4% and 61.2% of VAPs, 67.6% and 62.6% of CLABSIs, and, and higher for catheter-associated urinary tract infections.
 
Recommendations
Contact precautions are recommended in addition to standard precautions; add droplet if aerosol-generating procedure is anticipated. For ambulatory or home-care settings, use standard precautions.
 
There is no national recommendation for discontinuation of transmission-based precautions, and should be determined by patient clinical status and most recent culture isolates. However, colonization may come and go over several months.
 
For resistance information: MDRO Definitions (pdf)
 

MULTIDRUG-RESISTANT PSEUDOMONAS
Pseudomonas aeruginosa accounted for 8% of all healthcare-associated infections reported to the National Healthcare Safety Network (NHSN) during 2009–2010; 13% of these were multidrug-resistant. Drug resistance means that clinicians must resort to more expensive antibiotics with increased side effects.
 
Recommendations
Contact precautions are recommended in addition to standard precautions; add droplet if aerosol-generating procedure is anticipated. For ambulatory or home-care settings, use standard precautions.
 
There is no national recommendation for discontinuation of transmission-based precautions, and should be determined by patient clinical status and most recent culture isolates. However, colonization may come and go over several months.
 
For resistance information: MDRO Definitions (pdf)
 

CLOSTRIDIUM DIFFICILE
Clostridium difficile infection (CDI) is a common infection control challenge across the continuum of healthcare facilities, causing serious morbidity and mortality, and an estimated $1 billion in excess medical costs. Although Oregon’s rate of CDI (Standardized Infection Ratio (SIR) = 0.72) is less than the national average, data stratified by facility paints a different picture: 15 of 61 reporting reported SIRs >1.
 
Using rates from Oregon’s population-based CDI surveillance of 110.5–154.3 CDI cases per 100,000 residents, we estimated 1,768–2,469 cases would occur in the Tri-county area (Multnomah, Washington, Clackamas counties, estimated population 1.6 million), and 4,310–6,018 cases statewide (estimated population 3.9 million) per year.
 
While most cases are expected to be healthcare-related, the CDI surveillance showed that 52% of CDI cases in rural areas are community onset. 
 
Recommendations
Contact precautions are recommended in addition to standard precautions in all settings during active infection until resolution of symptoms and treatment.
 
Other key interventions for CDI prevention and response are the following:
  1. Identify infectious diarrhea: 1 episode of bloody diarrhea or >3 loose stools in 24h;
  2. Implement patient contact precautions for suspect CDI;
  3. Initiation of CDI testing as soon as CDI is suspected;
  4. Notification to medical staff;
  5. Enhanced environmental cleaning using CDI-approved methods, such as sporicidal cleaning products, attention to high-touch surfaces, hand washing with soap and water;
  6. Communication of CDI status and treatment on discharge or transfer to receiving facility; and
  7. Review of appropriate antibiotic use, required physician renewal, standardized treatment for certain clinical entities, facility antibiograms, and Infectious Diseases specialist consults.
For more information: C. difficile Disease A-Z