Colonization of Gram negative MDRO among hospitalized patients

Infection Control and Hospital Epidemiology April 2010 Vol 31, No 3 pages 330-337 by
Amy Weintraub,MD
Mollie Roediger,MS
Melissa Barber, MLT
Amy Summers,BS
Ann M. Fieberg,MS
James Dunn, RN
Venus Seldon, RN
Fluryanne Leach,MS
Xio-Zhe Huang, PhDMikeljon P. Nikolich, PhD
Glenn Wortmann,MD

Natural History of Colonization with Gram Negative MDRO among Hospitalized Patients

This study was to determine the anatomical sites of colonization of gram negative MDROs
This study was done at Walter Reed Army Hospital with deployed patients.

Common infection is acinetobacter from Iraq

Groin was the best site for gnmdro
perirectal and groin areas were the best site for esbl e coli

A prolonged study showed that colonization persisted with gnbacteria.

Carbepenem use was censored in this study. Its use was associated with an increased rate of esbl e coli.

Spontaneous decolonization is rare.


Infection Control and Hospital Epidemiology April 2010 Vol 31 No 4 pages 338-340

Lisa Maragakis,MD, MPH
Trish Perl, MD, MSc.

Commentary: How can we stem the rising tide of Multi-resistant gram negatie bacilli?

There is evidence that gram negative bacilli are an emerging threat in healthcare institutions.
We have extensive knowledge of MRSA and VRE. We have less knowledge about gram negative resistant orgs.

The Healthcare Infection Control ADvisory Committee's Management of Multi-drug Resistant Organisms in Health Care Settings
by JD Seigel
E Rhinhart
M Jackson
L Chairello

Healthcare Infection Control Practices Advisory Committee. Management of Multi drug reistant organisms in healthcare settings. 2006 http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf accessed April 5, 2010


This article describes a 2 tier level of interventions to prevent and respond to transmission of MDRO in healthcare settings.
The 2nd tier included intensified surveillance culture to identify those patients who are colonized.

In the article by Weintraub et al they have described anatomical sites beneficial to get accurate culturing.Colonizers tended to last about 2 months or longer with gram neg resistant bacilli.

large groups of patients are not identified by the use of clinical cultures, only by the use of surveillance cultures. These unidentified colonized patients provide a resevoir for potentially transmission to other patients.

Weintraub et al have described certain sites for gran neg bacilli, and there are other identified culture sites for MRSA and VRE. To do all these surveillance cutlures on each patient would put a big burden on the microbiology lab.

But miltary setting aside, Weintraub et al have shown that the hospital is the primary setting for MDRo transmission. Selected pateint groups should be cultured: those who havebeen recently hospitalized and specific populations such as military returning from deployment.

More data is needed before we plunge into large scale surveillance , which could direct resources from other important infection prevention practices.

Misinformation on the social netweork in regards to infections and antibiotics

Misinformation about antibiotics can travel to large audiences via twitter: study

"Dissemination of health information theough social networks: Twitter and antibiotics,"
by Daniel Scanfeld, MS,MA
Vanessa Scanfeld, MPP
Elaine Larson, RN, PhD, FAAN, CIC
appeared in the AMerican Journal of Infection Control, vol 38 Issue 3April 2010 published by Elsevier



Twitter site was used to asnlyize 52,153 updates which mentioned antibiotics between March 13, 2009 and July 31, 2009.

Tweets were categorized into 11 categories:
1. general use. Most common category. Ranged from updates about antibiotics, days needed to be on antibiotics, and how long before they start to work
2. advise/information. 2nd common transfer of personal advice and information
3. side effects/negative reactions. 3rd common . General comments about how antibiotics made them feel to not being able to drink alcohol or sun sensitivity.
4. diagnosis
5. resistance
6. misunderstanding or misuse. This compromised 700 of the 52,000 tweets. These could spread to large audiences.
7. positive reactions
8. animals
9. wanting and needing
10. cost
11 other

This review of Twitter shows that misinformation can be disseminated to quickly and to thousands of people.
Tjis study showed that social media sites need to be monitored contantly and explore wayshow they can positively impact public health.

Targeting Zero

A philosophy that every healthcare institution should be working toward a goal of zero healthcare acquired infections.
It is understood that not all HAIs (hosital acquired infections) are preventable.

APIC (association for Professionals in infection control) ofers many courses, webinars, and guidelines how to study and track HAIs.

The importance of surveillance with HAIs cannot be emphasized enough.
There are manual systems and computer generated systems.
I personally work on the manual system. My company which has many hospitals does not
have in place a computer generated infection control surveillance.
My hospital has an electronic medical record. Radiology, pharmacy, nursing, medicine, and
rehab are all included in this record. The lab system is an independent computer
system.

By manually collecting data one must:
check lab workdaily
correlate antibiotic therapy to labwork
count IV and PICC line days and number of patients and calulate out
count foley catheter patients and foley catheter days and calculate out
manually watch HH and PPE and calculate satistics
make sure every patient admitted to the hospital has lab work to allow for continuity
of care


It takes a team to target zero. Everyone who takes care of a patient is included. From
the dietary aide to nurses aide, to nurse, and physician.

MRSA methacillin resistant staph aureus

VRE vancomycin resistant enterococcus

MDRO multi drug resistent organism - resistant to 1 or more classses of antibiotics

HH hand hygien

PPE personal protective equipment

SSI surgical site infection

CaUTI foley catheter urinary tract infection

BSI: blood stream infection

VAP: ventilator acquired infection

AORN association of operating room nurses

APIC Association of professionals in infection control

CDC center for disease control

esbl extended spectrum beta lactimase

CABSI catheter associated bloodstream infection

KPC carbepenem resistant enterococcus

E Coli - escherichia coli

C Diff clostridium difficile

STAC short term acute care facility - acute hospital

LTAC - long term acute care

JC Joint commission

PICC peripheraly inserted central catheter

pseudo - pseudamonas aeruginosa

VISA vancomycin intermediate sensitive enterococcus

MSSA methacillin sensitive staph aureus

SNIF skilled nursing facility (nursing home, rehabillitation center)

IP infection preventionist

CHG chlorhexidine gluconate

CMS centers for medicare and medicaid services

HAI healthcare associated infection

CAI community acquired infection

ISDA Infectious Disease Society of AMerica

SHEA Society for HEalthcare Epidemiology of America

NHSN National Healthcare Safety Network

CVC Central venous catheter

AVA Association of vascular access

CABG coronary artery bypass graft

SCIP Surgical Care Inprovement Project

OR operating room

SPD Sterile processing department

WHO world health organization

CPC

enterobacteria resistance to the class of antibiotics called carbepenems

Who are enterobacteriaceae?

Large group of gram negative rods that inhabit human large intestine, soil, plants, and water.
They grow equally well in air (aerobic) and without air (anerobic).
Most common enterobacteri that are found in hospitalized patients and causing disease are:
eschericia coli, Enterobacter cloacae, Klebsiella pneumonia, Serratia marcesens, and roteus mirailis.

Enterobacteriacae rarely infect patients that are not immunocompromised. Which means the host defenses must be breached in order to cause infection therefore illness.
How does this occur? surgery, IVs, tube feedings, burns, ulcers, breaks in the skin, and contaminated food or beverages.

Enterobacteriacae can be resistant to first generation cephalosporins such as cefazolin and cephalexin. Cephalosporins work by killing bacterial cells by imparie cell wall synthesis. This is done by preventing the cross-binding of the peptoglycan polymers neecessary for cell wall formtion. The most comon form of antibiotic resistance from enterobacteria are the production of beta lactimase which can destroy the beta lactam ring by hydrolysis therefore prevent antimicrobial activity. Theses are known as the ESBL's.

They are a common source of infections in the hospitalized patient. Repeated use of antibiotic drug specific to the infection, and empirical Use before culutres are done) use have cause these enterobacteriaceae in some patients to become very resistant to treatment.

What are carbepenems?
They interfere with cell wall synthesis by pinding to penicillin-binding proteins (PBPs) enzymes which are essential for cell wall synthesis

Spectrum of activity;
It is due to the PBPs of bothe gram negative and gram positive bacteria.

Carbepenes are: Imipenem, merepenem, ertapenem

Why is there a concern with this class of medications?
Enterobacteriaceae are now becoming resistant to this class of drugs.
This is our last line of defense against infections in some patients. There is no other treatment.

Pharmaceutical companies are not investing time and money into antibiotics becasue resistance occurs faster than drugs are worked on.

So how to we prevent the spread of these resitant enterobacteriaceae?

Hand hygiene.

Contact precautions

Dr. Carnelli from Tel Aviv Hospital, Tel Aviv, Isreal is an epidemiologist working their. They had an outbreak several year ago. He had 2 patient floors set aside for CPC patient. He halso had dedicated staff to those floors . Which means the staff did not work anywhere else in the hosptal. Equipment did not leave the floor. There were special exceptions: such as the patient who needed ICU care. It took about 2 weeks for nonew cases of CPC to develop. (The did genotyping on all the CPC detected). The hospital remained CPC free for about 6 months. Dr, Carnelli then looked at where the patients were coming from. Those patients coming from skilled facilities where their exposure to the healthcare system was higher, had a high incidence of CPC. Therefore every patient entering Tel Aviv hospital is now screened for CPC.

At the kindred hospital where I work and our sister site, patient who develop CPC are placed in a private room, with very strict precautions.



web sites visitied for this article:

Http//:emergency.cdc.gov/cocoa/summaries/pdf/CarbepenemResistantEnterobac1709.interim.pdf
Htt//:www.aic.cuhk.edu.hk/web8/carbepenems.htm
http//:lib.bioinfo.pl/meid.23481

Kindred Hospital Antibiotic Stewardship Program

APIC Text for Infection Control: Volume II Scientific and Practice Elements

Yehuda Carmeli,MD, MPH, Chief of Epidemiology Tel AViv Sourasky Medical Center Tel Aviv, Israel, Research staff member Beth Israel Deaconess Medical Center,Boston, Ma lecture given 3/15/2010

Kenneth Lawrence, PharmD
Clinical Pharmacy Specialist - Infectious Diseases, Tufts Medical Center, Boston, Ma
Assistant Professor of MEdicine, Tufts University School of Medicine, Boston, Ma lecture given 3/15/2010

Antibiotic-Resistant Bugs in the 21st Century - A Clinical SUper-Challenge. New ENgland Journal of Medicine 360;5 January 29, 2009 pages 439-443
by Cesar Arias, MD, PhD, and Barbara Murray, MD

Environmental Hygiene

4th Annual Infection Control Today; Virtual Conference on Professional Deveoplment
February 9-10, 2010
Department of HEalth and Human Servic es: CDC: MMWR (Morbidity and Mortality Weekly)
June 6, 2003/ Volume 52/ No. RR-10

There is a correlation between the hospital environment and hospital acquired infections. Enironmental services(ES), housekeeping.

Must understand disease transmision; droplet, airborne, fomite, vector

Organisms in the environment: MRSA, VRE, C Diff, serratia, pseudamonas, staph aureus, strep

Idenify patients on admission.

Cleaning a hospital room: needs 10 minutes for cleaning solutions and contact time
also have to consider all posible high touch areas - bedside table, light switches,
overbed table, remote control and call bell, door knobs; electronic media equipment


see CDC website for picture of Hospital room with terminal clean that cultured positive.


Have to know if C diff has been in the environment, need to use -10 bleach solution.

Products: Phenols, quats, bleach pay attention to exact measurments


Housekeeping - environemental services - much feel a apart of the hospital team. Need the correct tools. Right education and orientation to the hospital environment. Need respect and connection to purpose.

Best Practices in the Sterile Processing Department (STP)

4th annual conference from Infection Control Today: Virtual Conference of Professional Development
Febray 9-10, 2010

Best Practices in the Sterile Processing Department (STP) by Nancy Chobin, RN, AAS< CSPDM


Guidelines from AAMI and AORN

STP was always the department that was not thought of. Today it is a major player in the hospital.

STP scrubs; physical barriers to this department. Controlled temperature 60-65oF and humidity controlled between 30-60%; and a negative pressure room with less than 10 air exchanges/hour.

clean equipment with reusable brushes; correct detergent or enzymatic cleaner - measure amounts correctly.

Regulatory agencies AAMI and AORN require weekly testing for effectiveness

This inistial cleaning is to reduce biofilm formations and debris left after decontamination

Have to know the water quality and temperature. The correct temperature needs to be used with enzymatic cleaners. If the temperature is too high the enzymatic detergent can be killed, if the temperature is too low the enzymatic detergents can be slo=uggish.

Standard Precautions used in the SPD. Need water repellent gowns and gloves.

Must know how to load sterilizers for optimal cleaning. Each pack has an expiration date on the outside of the package. One time use products should never be cleaned and reused.

Sterilization: steam must contact all surfaces in the packged equipment.
there are special cycles be aware of those peices of equipment that require this.

Ethelene oxide gas: minimal heat and aeration time

There are now infrared thermometer guns check the temperatures on packages.

Storage of sterilized equipment: 2" from outside wall; 8-10" from floor; 18" from ceiling

Process improvement: monitor compliance; PPE use; hand hygiene; loading sterilizers; packaging audits; audit of cleaning and sterilization cycles

There should be good communication between the SPD, OR, and the infection preventionist.



First always process equipment according to the manufacture's instructions for cleaning