Pennsylvania Patient Safety Advisory Multidrug-Resistant Organisms—Strategies to Reduce Infection Multidrug-resistant organisms (MDROs) are defined indicated that active surveillance culture specimens by the Centers for Disease Control and Prevention were collected but were sent to the lab without suffi- (CDC) as “microorganisms, predominantly bacteria, cient patient identification, which delayed the process that are resistant to one or more classes of antimicro- for timely identification of an MDRO. bial agents.”1 The challenges faced by the infectious One report noted concern by a patient’s family disease and infection control community are rising members when they received conflicting instructions exponentially as antimicrobial agents lose efficacy. regarding their need to adhere to contact precautions Prevention of the spread of these organisms within as the patient was moved from the ICU to a medical- healthcare facilities is becoming more critical each day.2 surgical unit. The family members indicated that the History of MDROs healthcare workers’ use of personal protective equip- ment, such as gowns and gloves, was inconsistent. Strains of gram-positive bacteria, including Staphy- The family reported that while some staff members lococcus aureus, account for almost 60% of the did wear gowns and gloves, others did not—including healthcare-associated infections (HAIs) noted in a a dialysis nurse who provided direct patient care. report on data from SCOPE, the Surveillance and This report illustrates how inconsistencies and mixed Control of Pathogens of Epidemiological Importance messages to patients and their families can erode program.3 Methicillin-resistant Staphylococcus aureus confidence in healthcare providers’ ability to deliver (MRSA) was first noted in the United States around appropriate care and prevent the spread of MDROs. 1968, and infection rates have steadily increased since It also demonstrates the role patients and their fami- then. By 2003, according to National Nosocomial lies can play in enforcing isolation protocols when Infections Surveillance (NNIS) system data, 59.5% they understand the requirements. of the S. aureus isolates in intensive care units (ICUs) were identified as MRSA.4 Additionally, vancomycin- Key Points of a Successful Transmission resistant Enterococcus accounted for approximately Prevention Program 28.5% of the pathogens noted in the same NNIS report. MRSA strain USA300-0114, identified within Evidence-based practice incorporating risk reduction the past few years, is seen with increasing frequency; it strategies is essential for acute, long-term, and ambula- is the predominant cause of community-acquired soft- tory care settings to prevent, control, and ultimately tissue skin infections.5,6,7 eliminate MRSA and other MDROs.9 Successful infection control programs incorporate the following Increasing resistance among the gram-negative bacte- key concepts detailed in the Association for Profes- ria (e.g., Acinetobacter, Enterobacter, Klebsiella, E. coli) sionals in Infection Control and Epidemiology’s and the subsequent clinical manifestations represent “Guide to the Elimination of Methicillin-Resistant the tip of yet another dangerous iceberg for patients Staphylococcus Aureus (MRSA) Transmission in Hospi- and healthcare providers alike. Extended-spectrum tal Settings”:10 beta-lactamases are a group of enzymes produced by a number of gram-negative bacteria, with resultant ■ A baseline risk assessment for MDROs as a means resistance to beta-lactam antibiotics such as penicil- to determine the incidence among the patient lin and cephalosporins. First detected in Germany in population 1983, these organisms can exhibit resistance patterns ■ Active surveillance cultures for patient care settings as for which no antimicrobial therapies exist.8 They mandated by state regulation (Pennsylvania Act 52 add to the alphabet of ever-increasing numbers of of 2007 requires that hospitals develop procedures MDROs, and the potential to cause HAIs is daunting. necessary for requiring cultures and screenings for Identification, isolation, and additional precautions nursing home residents admitted to a hospital, as are critical to preventing patient-to-patient spread of well as procedures for identifying other high-risk MDROs within facilities. patients admitted to the hospital.) PA-PSRS Reports ■ Evaluation of colonized nursing home residents for prompt placement and initiation of facility-specific A search of the PA-PSRS database yielded more than precautions 700 reports from 2004 through 2007 that indicated inconsistencies relating to isolation precautions ■ A well-established hand hygiene program that and identification of patients who were positive for includes readily available alcohol-based handrubs MDROs. Examples included patients admitted with ■ Prompt initiation of contact precautions for acute a known history of MDRO infection, for whom care patients with either a positive culture or a isolation was not promptly initiated; attending physi- known history of positive cultures for MDROs cians not wearing proper isolation garb; and properly gowned and gloved residents who entered and left the ■ An effective method to communicate a patient’s isolation room numerous times. In addition, reports MDRO status across the healthcare continuum Page 138 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 4—December 2008 Pennsylvania Patient Safety Advisory Antimicrobial Stewardship Programs Antimicrobial stewardship is a key component of — a clinical microbiologist, a multifaceted approach to preventing the emer- — an infection preventionist, and gence of resistant organisms. Studies indicate that antibiotic use is unnecessary or inappropriate in — an information system specialist. as many as 50% of cases in the United States. ■ Develop collaboration between the team and Over the past five years, focus has increased the hospital’s pharmacy and therapeutics on interventions intended to decrease bacterial committee. resistance or reduce superinfection, including infec- tions associated with Clostridium difficile colitis. ■ Demonstrate support of and collaboration Consistent cost savings, together with a reduction with facility administration and medical staff in resistance patterns, have been recognized after (i.e., “buy in from the top down”). these interventions were instituted. It is documented ■ Promote education in collaboration with active that in most instances, changes in infection control intervention. procedures were implemented at the same time as ■ Develop evidence-based practice guidelines the antimicrobial interventions, which would influ- incorporating local resistance patterns and ence the success of these programs. Data from antibiotic usage. well-controlled studies relating to the effect that these programs have on resistance are somewhat ■ Institute formulary restriction policies, including limited, but documentation does exist that antibiotic determining which drugs are placed on hospital stewardship reduces rates of Clostridium difficile- formulary. associated disease, resistant gram-negative bacilli, ■ Institute policies for de-escalation of empirical and vancomycin-resistant Enterococcus infection.1,2 antimicrobial therapy on the basis of culture The most effective means of improving antimi- results. crobial stewardship involves a comprehensive ■ Institute policies for dose optimization based on program that incorporates multiple strategies and a case-by-case review, causative organism, site collaboration among various specialties within a of infection, and drug characteristics. given healthcare institution. This program should ■ Develop clinical criteria and guidelines allowing be considered an important component of patient a switch from parenteral to oral agents. safety in every healthcare institution and may become mandatory in the future. ■ Audit antimicrobial usage, which should be con- ducted by an infectious disease physician or a Suggested Elements of a Stewardship Program clinical pharmacist trained in infectious disease drug management, together with feedback. The following elements of a multifaceted program, recommended by the Infectious Diseases Society Notes of America and the Society for Healthcare Epide- 1. Dellit TH, Owens RC, McGowan JE Jr, et al. Infec- miology of America “Guidelines for Developing tious Diseases Society of America and the Society an Institutional Program to Enhance Antimicro- for Healthcare Epidemiology of America guidelines bial Stewardship,” should be considered and for developing an institutional program to enhance implemented:3 antimicrobial stewardship. Clin Infect Dis 2007 Jan 15;44(2):159-77. ■ Form a multidisciplinary antimicrobial steward- 2. Fishman N. Antimicrobial stewardship. Am J Infect ship team including Control 2006 Jun;34(5 Suppl 1):S55-63. — an infectious disease physician, 3. MacDougall C, Polk RE. Antimicrobial stewardship — a clinical pharmacist, programs in health care systems. Clin Microbiol Rev 2005 Oct;18(4):638-56. ■ A system to monitor staff compliance with contact “Antimicrobial Stewardship Programs”) as one of precautions and hand hygiene four main strategies. The other strategies include the diagnosis and treatment of clinical infection, infec- ■ A system to provide feedback and education to staff tion prevention, and transmission prevention. CDC’s online campaign includes tools for clinicians in vari- ■ An environmental cleaning checklist/audit tool to ous clinical settings, such as fact sheets, posters, slide prevent/control the spread of MDROs via surfaces sets, and tips for patients. Additional information and patient care equipment about the campaign is available online at http://www. National Approach to MDRO Prevention cdc.gov/drugresistance/healthcare/default.htm.11 CDC’s Campaign to Prevent Antimicrobial Resis- CDC’s National Healthcare Safety Network recently tance in Healthcare Settings notes the growing added an additional patient safety component: the struggle with MDROs and includes the critical need combined MDRO and Clostridium difficile-associated for judicious use of antibiotics (see box article on disease (CDAD) module. By employing this module, Vol. 5, No. 4—December 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 139 Pennsylvania Patient Safety Advisory facilities may choose to document and/or monitor Summary infections, prevalence, and prevention process mea- The emergence of increasing bacterial resistance to sures or active surveillance testing related to either antimicrobial measures, rising infection rates in facili- MDROs or CDADs.12 ties, and subsequent clinical manifestations represents the tip of another iceberg for patients and healthcare Pennsylvania Mandates providers. Commitment, sufficient funding, and sufficient staffing, as well as behavioral and cultural The Pennsylvania Health Care-Associated Infection changes and modified thought processes, are necessary and Prevention Control Act of 2007, Act 52, man- in regional and national efforts to eliminate MDROs. dates that the following be implemented in healthcare facilities: Notes 1. Siege JD, Rhineheart E, Jackson M, et al. Healthcare ■ Procedures for requiring active surveillance cul- Infection Control Practices Advisory Committee. Man- tures and screenings for all nursing home residents agement of multidrug-resistant organisms in health care admitted to a hospital settings, 2006. Am J Infect Control 2007 Dec;35(10 Suppl 2):S165-93. ■ Procedures for identifying other high-risk patients admitted to the hospital, using active surveillance 2. Moellering R, Graybill J, McGowan J, et al. Antimi- crobial resistance prevention initiative—an update: cultures (High-risk patients are not defined by Act proceedings of an expert panel on resistance. Am J Infect 52 of 2007 and are to be determined by individual Control 2007 Nov;35(9):S1-23. hospitals.) 3. Wisplinghoff H, Bishchoff T, Tallent SM, et al. Nosoco- ■ Procedures and protocols for staff who have poten- mial bloodstream infections in US hospitals: analysis of tially been exposed to a patient or resident known 24,179 cases from a prospective nationwide surveillance to be colonized or infected with MRSA or MDRO, study. Clin Infect Dis 2004 Aug 1;39(3):309-17. including cultures and screenings, prophylaxis, and 4. National Nosocomial Infections Surveillance System. follow-up care (To date, industry standards for expo- National Nosocomial Infections Surveillance (NNIS) sure of staff to MRSA or MDRO are nonexistent.) System Report, data summary January 1992 through June 2004, issued October 2004. Am J Infect Control ■ Procedures and processes for notifying a receiving 2004 Dec;32(8):470-85. healthcare facility or ambulatory surgical facility of 5. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Meth- any patient known to be colonized before transfer icillin-resistant S. aureus Infections among patients within or between facilities in the emergency department. N Engl J Med 2006 Aug;355(7):666-74. Active surveillance cultures in combination with isolation precautions and the use of barriers are 6. Gonzalez BE, Martinez-Aguilar G, Hulten KG, et al. consistent with most guidelines for the control of Severe Staphylococcal sepsis in adolescents in the era of community-acquired methicillin-resistant Staphylococcus these microbes.13 aureus. Pediatrics 2005 Mar;115(3):642-8. For a description of the Pennsylvania Patient Safety 7. King MD, Humphrey BJ, Wang YF, et al. Emergence of Authority’s role and progress and goals of Act 52, see community-acquired methicillin-resistant Staphylococ- the article in the June 2008 issue of the Pennsylvania cus aureus USA 300 clone as the predominant cause of Patient Safety Advisory at http://www.psa.state.pa.us/ skin and soft-tissue infections. Ann Intern Med 2006 Mar psa/lib/psa/advisories/v5n2june_2008/ 7;144(5):309-17. jun_2008_v5_n2_article_act52.pdf.14 8. Knothe H, Shah P, Kremery V, et al. Transferable resistance to cefotaxime, cefoxitin, cefamandole and Summary points of the Act are available online from cefuroxime in clinical isolates of Klebsiella pneu- the Hospital & Healthsystem Association of Penn- moniae and Serratia marcescens. Infection 1983 sylvania at http://www.haponline.org/downloads/ Nov-Dec;11(6):315-7. HAP_Summary_Act_52_of_2007_07262007.pdf.15 9. Muto CA, Jernigan JA, Ostrowsky BE, et al. SHEA The call to action against MDROs is ongoing across guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus Pennsylvania. Active government, community, and and enterococcus. Infect Control Hosp Epidemiol 2003 healthcare alliances are forming and working together May;24(5):362-86. to gain control and prevent the spread of these multidrug-resistant threats to patient safety.16 CDC’s 10. Association for Professionals in Infection Control and Epidemiology, Inc. Guide to the elimination of methi- MDRO/CDAD module will be strongly considered cillin-resistant Staphylococcus aureus (MRSA) transmission for integration into the mandatory reporting require- in hospital settings [online]. 2007 Mar [cited 2008 Nov ments in the future, as an additional step towards 24]. Available from Internet: http://www.ihatoday.org/ best practices. issues/quality/apicguide.pdf. Page 140 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 4—December 2008 Pennsylvania Patient Safety Advisory 11. Centers for Disease Control and Prevention (CDC). 14. Pennsylvania Patient Safety Reporting System. Act 52 of CDC campaign to prevent antimicrobial resistance in 2007: the Authority’s role, progress to date, and future the healthcare settings [Web site]. Atlanta (GA): CDC. goals. Pa Patient Saf Advis [online]. 2008 Jun [cited Available from Internet: http://www.cdc.gov/ 2008 Sep 17]. Available from Internet: http://www.psa. drugresistance/healthcare/default.htm. state.pa.us/psa/lib/psa/advisories/v5n2june_2008/ jun_2008_v5_n2_article_act52.pdf. 12. Centers for Disease Control and Prevention. Protocol: multidrug-resistant organism (MDRO) and Clostridium 15. Hospital & Healthsystem Association of Pennsylvania. difficile-associated disease (CDAD) module [online]. HAP summary: Act 52 of 2007: The Health Care-Asso- 2008 Mar 19 [cited 2008 Nov 24]. Available from ciated Infection and Prevention Control Act [online]. Internet: http://cdc.gov/ncidod/dhqp/pdf/nhsn/ 2007 Jul 26 [cited 2008 Sep 17]. Available from Internet: MDRO_CDAD_Protocol_v4REV.pdf. http://www.haponline.org/downloads/ HAP_Summary_Act_52_of_2007_07262007.pdf. 13. Aboeleal S, Saiman L, Stone P, et al. Effectiveness of barrier precautions and surveillance cultures to control 16. The Health Care Improvement Foundation. Fight transmission of multidrug-resistant organisms: a system- MRSA! Alliance [online]. 2008 [cited 2008 Sep 17]. atic review of the literature. Am J Infect Control 2006 Oct; Available from Internet: http://www.hcifonline.org/ 34(8):484-94. section/programs/mrsa. Vol. 5, No. 4—December 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 141 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 5, No. 4—December 2008. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2008 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the PA-PSRS program, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the PA-PSRS program or the Pennsylvania Patient Safety An Independent Agency of the Commonwealth of Pennsylvania Authority, see the Authority’s Web site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.