A look at multidrug-resistant organisms

MRSA is among the deadly antibiotic-resistant bacteria identified as urgent or serious threats by the Centers for Disease Control and Prevention.

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Each year, health care-associated infections (HAIs) are a documented source of increased mortality and morbidity, significant costs for care delivery, and have a negative impact on the patient experience. HAIs are typically preventable through the implementation of recommended evidence-based practices.

The Centers for Disease Control and Prevention’s (CDC’s) Healthcare Infection Control Practices Advisory Committee has authored numerous guidelines and guidance statements that directly reduce the risk for transmission of HAIs such as multidrug-resistant organisms (MDROs) and other emergent pathogens such as Ebola virus disease.

These core recommendations can guide clinicians and other health care personnel in adherence to well-studied interventions that significantly can reduce the overall incidence of HAIs and occupational exposure to health care personnel.

Systems and patients

Today’s health care professionals are caring for far more acutely ill patients than ever before, and some of them may be infected with antibiotic-resistant bacteria. These bacteria are resistant to the stockpile of antimicrobial agents that are available today.

These microorganisms can be found in all health care settings, both inpatient and outpatient care environments, and are particularly prevalent in health care settings where the patients are exposed routinely to antibiotics.

It is estimated that six urgent or serious antibiotic-resistant pathogen threats in addition to Clostridium difficile can cause HAIs. Moreover, one in four catheter- and surgery-related HAIs are caused by six specific bacteria in certain kinds of hospitals.

These six bacteria are among the most deadly antibiotic-resistant bacteria identified as urgent or serious threats by the CDC. They include carbapenem-resistant Enterobacteriaceae (CRE), methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamases-producing Enterobacteriaceae, vancomycin- resistant enterococci (VRE), multidrug-resistant Pseudomonas aeruginosa, and multidrug-resistant Acinetobacter baumannii.

The CDC is working aggressively with the Food and Drug Administration to address the drug pipeline for antibiotics.

Antibiotic vs. antimicrobial

The term antibiotic is used to describe medications that are ingested, injected or administered to affect the systemic systems within the human body.

These medications are found in the form of oral pills, liquids, injectable solutions and solutions administered intravascularly. Antibiotics are prescribed by a health care provider and are designed to be taken over a specific duration of time to combat the infection.

Antimicrobials, on the other hand, are a much broader category that includes agents designed to reduce or kill microbial life, including antibacterial soaps, environmental surface disinfectants, alcohol-based hand sanitizers, skin antiseptics and some topical skin creams.

The mechanism of action for antibiotics is extremely different from that of antimicrobial products. Many antimicrobial products are designed to work topically or locally on isolated surfaces such as nonliving environmental surfaces or medical devices.

When used according to the manufacturer’s instructions, antimicrobial agents should not contribute to the threat of antibiotic resistance.

Prevention steps

The CDC has released new recommendations to prevent antibiotic-resistant infections in a new targeted Vital Signs report. This report highlights both the impact of antibiotic-resistant infections and, more importantly, the necessary steps to mitigate the transmission and acquisition of these deadly pathogens.

The CDC has described three basic strategies to prevent these infections: focusing on preventing infections from catheters and after surgery; preventing bacteria from spreading; and improving overall antibiotic use. Each of these core strategies contains additional recommendations such as prompt removal of catheters, use of hand-hygiene agents, and use of personal protective equipment and isolation precautions.

For instance, regarding preventing infections from catheters and after surgery, the CDC suggests using catheters only when needed; following recommendations for safer surgery and catheter insertion and care; and removing catheters from patients as soon as they are no longer needed.

Likewise, to prevent bacteria from spreading, the CDC recommends improving hand hygiene; using gloves, gowns and dedicated equipment for patients who have resistant bacteria; and knowing about antibiotic-resistant HAI outbreaks in the hospital and region (e.g., promote coordinated action for prevention).

Finally, to improve overall antibiotic use, the CDC tells hospitals to obtain cultures and start antibiotics promptly, especially in the case of sepsis; use cultures to reassess the need for antibiotics and stop the use of antibiotics as soon as they are no longer needed; and use the appropriate antibiotic in the proper dosage, frequency and duration when antibiotics are necessary.

CRE microbes

CRE is a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. Klebsiella species and Escherichia coli — examples of gram-negative bacteria in the Enterobacteriaceae family — are a normal part of the human gut bacteria that can become carbapenem-resistant.

The enzymes Klebsiella pneumoniae carbapenemase-1 (KPC) and New Delhi metallo-beta-lactamase-1 (NDM) break down carbapenems and make them ineffective. Both of these enzymes, as well as the enzyme Verona Integron-mediated metallo-beta-lactamase, also have been reported in Pseudomonas.

CRE has been the subject of news stories and outbreak investigations recently in the state of California due to an outbreak associated with duodenoscopes.

Many CRE bacteria within the microbial class have been pandrug-resistant to all known antibiotics, and others are quickly on a similar path for developing resistance. It is estimated that CRE microbes can contribute to death in up to 50 percent of patients who become infected. This leads to unnecessary mortality and morbidity.

The CDC recommends the following steps for CRE:

• Work with the organization’s medical laboratory and determine if patients with CRE are contained within the facility. Closely monitor CRE infections for potential outbreaks and collaborate with the facility’s infection preventionist, infectious disease physician, environmental services (ES) professionals and medical laboratory team to establish a system of monitoring for potential CRE outbreaks.
• Place patients currently or previously colonized or infected with CRE on contact precautions immediately. Whenever possible, dedicate patient rooms, equipment and staff to CRE patients to reduce the risk for potential transmission.
• Wear an impervious gown and gloves when caring for patients with suspected or confirmed CRE.
• Perform hand hygiene using an alcohol-based hand rub or wash hands with soap and water before and after contact with the patient. Offer the patients opportunities for hand hygiene as well.
• Ensure that the facility’s medical laboratory immediately notifies the patient’s provider and ES professionals when CRE is identified and confirmed.
• Administer antibiotics only when clinically indicated.<
• Discontinue devices such as urinary and rectal catheters as soon as they are no longer medically necessary.

Impact of C. diff

A recent report from the CDC estimated that roughly 500,000 C. difficile infections occurred in the U.S. in 2011, of which 29,000 of those patients died as a complication of the infectious disease within 30 days of the initial diagnosis while hospitalized. Additionally, 83,000 of the patients with infection experienced at least one recurrence within 30 days of the initial diagnosis.

The major risk factor that contributes to the development of this disease is the overuse or inappropriate use of antibiotics. Antibiotics kill the natural, protective flora found in the patient’s gut, which can then allow the C. difficile flora to overtake the bowel and result in infection.

CDC studies have demonstrated that 30 to 50 percent of antibiotics prescribed in U.S. hospitals are unnecessary or clinically incorrect. C. difficile is a tremendous source of mortality and morbidity to the health care delivery system.

The CDC recommends the following steps for C. difficile:

• Work with prescribers and the clinical pharmacist to ensure that antibiotics are indicated for the patient’s condition and carefully taken by the patient according to the prescribed directions. Also, it is important to discontinue antibiotics as soon as they are not medically necessary.
• Order a C. difficile test if the patient has had three or more unformed stools within a 24-hour time period.
• Isolate patients with suspected or confirmed C. difficile disease immediately.
• Follow isolation precaution guidelines when caring for patients with suspected or confirmed C. difficile (i.e., wearing gloves and a gown) even during short visits.
• Wash hands manually with soap and water to effectively remove the spores from the hands. Alcohol-based hand rubs are not effective for removing spores from the hands.
• Collaborate with the facility’s ES professionals to ensure that room surfaces are cleaned thoroughly on a daily basis and also upon discharge. It is important to use an Environmental Protection Agency-approved, spore-killing disinfectant for units where there is potential transmission.

Reducing the risk

Emergent pathogens and antimicrobial resistance continue to plague the global health care system.

However, basic infection prevention and control practices will greatly assist health care professionals and the entire health care delivery team in reducing the risk for transmission of these pathogens.

Maintaining a clean and sanitary environment through effective cleaning and disinfection practices, reducing the overuse of antibiotics, sanitizing hands often and keeping the patients’s own skin intact will reduce the potential risk for transmitting many emergent pathogens such as CRE, Ebola virus disease and C. difficile.

In addition, health care professionals should carefully follow the evidence- based recommendations from the CDC for isolation precautions, use of personal protective equipment, disinfection and sterilization, and hand hygiene.

A true difference can be made in reducing the incidence of these infections as well as decreasing the associated mortality and morbidity through a coordinated approach across the entire continuum of care as well as active engagement with patients. HFM

J. Hudson Garrett Jr., Ph.D, MSN, IP-BC, is vice president of clinical affairs for PDI Inc. and is an international expert in infection prevention and control. He also serves as the industry liaison for the board of directors of the Association for the Healthcare Environment, a personal membership group of the American Hospital Association. He can be reached at Hudson.garrett@pdihc.com

Acute care hospitals

Patients can get health care-associated infections (HAIs) while receiving medical treatment in a health care facility. Working toward the elimination of HAIs is a Centers for Disease Control and Prevention (CDC) priority. The infections listed below are among the most common.

Central line-associated bloodstream infections (CLABSIs)

1 in 6 CLABSIs were caused by urgent or serious antibiotic- resistant threats.

Catheter-associated urinary tract infections (CAUTIs)

1 in 10 CAUTIs were caused by urgent or serious antibiotic- resistant threats.

Surgical-site infections (SSIs)

1 in 7 SSIs were caused by urgent or serious antibiotic-resistant threats.

Source: Adapted from CDC Vital Signs, March 2016

Centers for Disease Control and Prevention resources on superbug prevention

• Carbapenem-resistant Enterobacteriaceae in Healthcare Settings
• Clostridium difficile Infection
• Making Health Care Safer
• National Strategy to Combat Antibiotic-Resistant Bacteria
• Preventing Antibiotic Resistant Infections, electronically accessed from
• Recommendations for Clinicians for Clostridium difficile: What Healthcare Providers Can Do