Multi Drug Resistant Multi Drug Resistant Organisms (MDROs) in Health Organisms (MDROs) in Health

Care setting : Care setting :

use of standardized metrics to use of standardized metrics to monitor local prevention effortsmonitor local prevention efforts

Dr. Ashok Rattan,

Chief Executive,

Fortis Clinical Research Ltd.,

Adviser,

Religare SRL Diagnostics labs in

Fortis / Escorts Hospitals, Delhi & NCR

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19801975 1985 1990 1995 20001997

VISAVISA

VREVRE

PRSPPRSP

MRSAMRSA

MRSEMRSEPercentage ofPathogensResistant toAntibiotics

Increasing Incidence of Resistance in the US

MRSE, MRSA, VRE, PRSP, GISA 1980-2006

VRSAVRSA

2006

Crisis of Pan Resistant Bacteria

• Pre existing or Acquisition of new resistance by bacteria

Mutation

Spread within clone

Vertical

Horizontal

• Expansion of clone &

Dissemination of resistant bacteria

Biological PhenomenonBiological Phenomenon

Partly Mechanical PhenomenonPartly Mechanical Phenomenon

Antibiotic Stewardship Programme

• Effective antimicrobial stewardship– Audit & feedback– Guidelines & algorithms– Antibiotic order form– Combination– De escalation– Dose optimization– Parentral oral– Cycling

• Comprehensive Infection control– Managing data and

information– Policies & procedures– Regulatory requirements– Employee health– Prevent transmission,

investigate outbreaks– Education & training– Mobilize resources: human

& financial

Monitoring MDROs is important

• To– Detect newly emerging antimicrobial profile– Identify vulnerable patient population– Assess need for & effectiveness of, intervention

• Why– Incidence has increased in the past decades– Options for treatment are limited – Has important implications for patient safety– Associated with prolonged stay, costs and mortality

Which MDROs should we monitor ?Choice need to be facility based

• May include:

– MRSA & VRSA

– VRE

– MDR GNB

• Pseudomonas aeruginosa

• Acinetobacter baumannii

• Klebsiella pneumoniae

• Escherichia coli

• Before staring make sure clear cut definitions are in place & understood by all participating in surveillance

MDROs Metrics5 categories of outcome measures

1. Tracking patients

2. Monitoring susceptibility patterns

3. Estimating infection burden

4. Estimating Exposure burden

5. Quantifying healthcare acquisition

Preventive Process Measures• Monitor adherence to Hand Hygiene• Monitor adherence to Gown & Glove use• Monitor adherence to Active Surveillance Testing

1. Tracking patient

• A. Line listing: – Not a rate, so no denominator, – No defined period, continuously updated– Essential elements of line listing:

» Pt identification,» Hospital location» Date of admission» Date and time of sample collection » Source of sample» Date of first positive

– Useful to flag patients for » identification and » contract isolation

A. Line Listing• Simple• Could be the only essential metrics for rare MDROs• For common MDROs like MRSA it provides

– Identification of patient

– History of infection or colonization

• Can trigger & follow outbreak investigation for new or rapidly emerging MDROs

• Initial part of any risk assessment; identifies pts with a prior history of colonization or infection. This might be the only metrics necessary for rare MDROs (eg VRSA)

1. Tracking patientA. Line Listing

• Type of microbiology data required:– Clinical culture data (& AST data if available)

• Numerator– Pt with newly recovered MDRO isolate (regardless of

specimen source) by HCF

• Denominator– None

• Surveillance interval– Continuous

• Location of use– Whole HCF

2. Monitoring susceptibility pattern

• A. Antibiogram:• To provide guidance for antimicrobial prescription• Monitor progress is assessing proportion of MDRO resistant to certain

antibiotics of interest

• CLSI Recommendations of Antibiogram:1.Methods of summarizing susceptibility data2.Report results in “percent susceptible”3.Organisms morphological grouping4.Duplicate isolate notification5.Description of exact collection period.6.Number of isolates for each organism.7.Reporting only organisms with greater than 30 isolates.8.Use of Generic names of antimicrobials.9.Utilization of CLSI approved antimicrobial abbreviations.10.Utilization of “dash” to describe susceptibility data not reported11.Annual reporting of results

2. Monitoring Susceptibility Pattern

A. Antibiogram• Type of microbiology data required:

– Clinical culture data • Numerator

– Number of first susceptible clinical isolates (regardless of specimen source) per pt for each unit or HCF

• Denominator– Total number of isolates (both S & R) per pt. for each unit or HCF

• Surveillance interval– Atleast annually

• Location of use– Whole HCF (consider use for specific units or populations)

3. Estimation of Infection Burden

A. Metrics:

Incidence or Incidence density rate of hospital onset bacteremia

Basic for all MDROs, especially for emergence of new resistance

3. Estimation of Infection BurdenA. Incidence density rate of hospital onset bacteremia

• Type of microbiology data required– Blood culture data only

• Numerator– Number of MDRO isolates recovered from blood samples for

each unit or HCF > 3 calendar days after admission to unit or HCF

• Denominator– 100 pt admissions (incidence); 1000 pt days ( inc. density)

• Surveillance interval– Monthly

• Location of use– Specific units (consider use for whole HCF)

B. Metrics:

Nosocomial organism specific infection incidence or incidence density

Useful for assessing burden of a specific organism regardless of extrinsic risk factors (eg catheter or ventilator use)

3. Estimation of Infection Burden

3. Estimation of Infection Burden B. Nosocomial organism specific infection incidence

• Type of microbiology data required– Clinical culture data only

• Numerator– Number of hospital onset MDRO infections meeting standard

infection criteria

• Denominator– 100 pt admissions (incidence); 1000 pt days ( inc. density)

• Surveillance interval– Monthly

• Location of use– Specific units (consider use for whole HCF)

C. Metrics:

Organism specific, devise associated associated incidence density :

Useful for assessing the burden of specific device associated infections.

3. Estimation of Infection Burden

3. Estimation of Infection Burden

c. Organism specific, devise associated incidence density • Type of microbiology data required

– Clinical culture data only

• Numerator– Number of devices associated MDRO infections

• Denominator– 1000 device days

• Surveillance interval– Monthly

• Location of use– Specific units (consider use for whole HCF).

D. Metrics:

Organism & procedure specific incidence density

Useful for assessing the burden of specific procedure associated infections or in specific populations

3. Estimation of Infection Burden

3. Estimation of Infection Burden D. Organism & procedure specific incidence density

• Type of microbiology data required– Clinical culture data only

• Numerator– Number of procedures associated MDRO infections

• Denominator– 100 procedures

• Surveillance interval– Monthly (or quarterly)

• Location of use– Not applicable

4. Estimating Exposure BurdenA. Metrics:

Overall prevalence or prevalence density rate based on clinical culture data

Reasonable initial risk assessment, underestimates hidden reservoirs for MRSA, VRE & MDR GNB

4. Estimating Exposure Burden A. Overall prevalence or prevalence density rate based on

clinical culture data

• Type of microbiology data required– Clinical culture data only

• Numerator– Number of first MDRO isolated per pt per unit regardless of time

pt spent in the unit and number of pts with history of colonization or infection

• Denominator– 100 pt admission (P); 1000 pt days (prevalence density)

• Surveillance interval– Monthly (or quarterly)

• Location of use– Specific unit (consider use for whole HCF)

4. Estimating Exposure BurdenB. Metrics

Overall prevalence or prevalence density rate based on clinical culture and AST data

Very useful for robust assessment of intervention if conducting AST

4. Estimating Exposure BurdenB. Overall prevalence or prevalence density rate based on

clinical culture and AST data

• Type of microbiology data required– Clinical culture and AST data

• Numerator– Number of first MDRO isolated per pt per unit regardless of time

pt spent in the unit and number of pts with history of colonization or infection

• Denominator– 100 pt admission (P); 1000 pt days (prevalence density)

• Surveillance interval– Monthly

• Location of use– Specific unit (consider use for whole HCF)

4. Estimating Exposure BurdenC. Metrics

Admission prevalence rate based on clinical culture data with or without AST

Useful adjunct metrics if there is concern about importation from community or other HCF

4. Estimating Exposure BurdenC. Admission prevalence rate based on clinical culture data with or without AST

• Type of microbiology data required– Clinical culture data with or without AST

• Numerator– Number of first MDRO isolated per pt per unit < 3 calendar days

after admission to the unit and number of pts with history of colonization or infection

• Denominator– 100 pt admissions

• Surveillance interval– Monthly

• Location of use– Specific unit (consider use for whole HCF)

4. Estimating Exposure BurdenD. Metrics

Point prevalence rate based on point prevalence surveys

* Useful adjunct metric for HCF not conducting routine AST. * Help provide as estimate of the degree to which clinical

culture data underestimates the full reservoir. * Could guide HCF when to start AST in select population

or units. * Very useful in defining high risk areas or population of an

HCF.

4. Estimating Exposure BurdenD. Point prevalence rate based on point prevalence surveys

• Type of microbiology data required– Clinical culture and AST data

• Numerator– Number of MDRO isolated per pt per unit or HCF

• Denominator– 100 pt admissions

• Surveillance interval– Point in time

• Location of use– Specific unit (consider use for whole HCF)

5. Quantifying Healthcare Acquisition

A. Metrics:

Incidence or incidence density rate of hospital onset MDRO

Useful for VRE & MDR GNB during outbreak, but underestimates the hidden reservoir

5. Quantifying Healthcare Acquisition

A. Incidence or incidence density rate of hospital onset MDRO • Type of microbiology data required

– Clinical culture data only

• Numerator– Number of first MDRO isolated per pt per unit > 3 calendar days

after admission to the unit, excluding pts with history of colonization or infection

• Denominator– 100 pt admissions (incidence); 1000 pt days ( I. density)

• Surveillance interval– Monthly

• Location of use– Specific units (consider use for whole HCF)

5. Quantifying Healthcare AcquisitionB. Metrics:

Incidence or incidence density rate of hospital onset MDRO

Provides a more useful metric than incidence based on clinical culture data, if conducting routine AST

5. Quantifying Healthcare Acquisition

B. Incidence or incidence density rate of hospital onset MDRO • Type of microbiology data required

– Clinical culture and AST data

• Numerator– Number of first MDRO isolated per pt per unit > 3 calendar days

after admission to the unit, excluding pts with history of colonization or infection

• Denominator– 100 pt admissions (incidence); 1000 pt days ( I. density)

• Surveillance interval– Monthly

• Location of use– Specific units (consider use for whole HCF)

Category of Measure Basic or

measure Advanced

Tracking Line Listing B

Susceptibility pattern Antibiogram B

Infection Burden Proxy Nosocomial MRSA B

Bacteremic incidence

Nosocomial MRSA A

infection incidence

MRSA device or procedure A

associated infection

Category of Measure Basic or measure Advanced

Exposure Burden Overall MRSA prevalence A based on clinical cultures

Overall prevalence with Active Surveillance Testing A

MRSA admission prevalence A

Point prevalence survey A

Healthcare acquisition MRSA incidence based on B (MRSA) clinical cultures A

Incidence based on AST A

These metrics are for monitoring of MDROs burden in house and monitoring response to

interventions within the healthcare facility.

Should not be used for inter facility comparisons

Thank you for your attentionThank you for your attention