multi drug resistance organism update 2024

MDRO

1. MULTIDRUG RESISTANT ORGANISMS (MDRO) DR MOHD HELMY BIN ABU BAKAR PENASIHAT UNIT KAWALAN INFEKSI HOSPITAL JELEBU

2. MDRO SURVEILLANCE MANUAL 3 rd Edition 2022

3. 1. INTRODUCTION MDROs are defined as microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents. According to CDC’s Antibiotic Resistance Threats Report, each year, more than 35,000 people in the U.S die because of antibiotic-resistant infections, with more than 2.8 million infections. The risk factors associated with MDROs infection and colonization include those with severe underlying medical conditions (e.g., cancer, end stage renal disease); history of recent surgery; presence of indwelling medical devices (e.g., urinary catheters or endotracheal tubes).

4. 1. INTRODUCTION Th e most com m on i n fection caus e d b y MD R O is bloodstream infections associ a ted w i th severe (BSIs) an d have been adv e r se cl i n ic a l outcome s , leading to increased mortality, prolonged hospital stay, and increased healthcare costs. Surveillance is an essential component of MDRO control program in hospitals. It assists in detection of newly emerging pathogens, monitoring epidemiologic trends, and measuring the effectiveness of interventions especially the IPC interventions.

5. 1. INTRODUCTION Multidrug - Resistant Organisms surveillan c e i s a co n ti n uou s , ( M DRO) activ e , laboratory-based surv e i l la n ce on of the clin i c al i n c idence o f sp e ci fi ed organis m s interests. All laboratories shall use a standard definition for identification and reporting of these MDROs (See Appendix 1). Th i s sur v ei l lance p rogram healthcare associated m eas u res both i n fect i on and colonization attributed to the MDRO of interest.

6. 2. OBJECTIVES The objective of MDRO surveillance program is to determine the rate and trend of specified MDROs in all hospitals in Malaysia using standardized laboratory and clinical criteria. This is preven t ion essenti a l and for early detection of outbreak and timely investigation and institution of control measures.

7. 3. METHODOLOGY a) Population under surveillance: The population under surveillance is ALL INPATIENTS. EXCLUSION CRITERIA : Cases from D e p a r t me n t of Emerg e n c y , cli n ic o r oth e r outpatient services. Cases previous l y i d e nti fi e d at ot h er ac u t e care fa c ilities / hospitals. Cases r e - a dmitt e d w ith th e s a me M D ROs w ithin o ne y ear EXCEPT for secondary blood stream infection. Screening cultures that were done NOT for contacts of index patient with MDROs. e.g., rectal swab screening for CRE prior to ICU admission, or rectal swab screening for CRE prior to patient’s transfer to other healthcare facilities. NOTE: Screening cultures that were done for contacts of index patient with MDROs are included in this surveillance e.g., rectal swab screening for CRE for close contacts of index patient with CRE. Secondary bloodstream infection (BSI) should be reported.

8. 3. METHODOLOGY The MDROs under surveillance are: Methicillin-resistant Staphylococcus aureus (MRSA) E x tende d -spectrum b et a -l a ctam ases (E S B L ) p roduc i ng Klebsiella pneumoniae Extended-spectrum beta-lactamases (ESBL) producing Escherichia coli Multidrug-resistant Acinetobacter baumanii Carbapenem-resistant Entrobacterales (CRE) Vancomycin-resistant Enterococcus (VRE)

9. 3. METHODOLOGY Case definitions MDRO case definition must fulfill all three criteria: Isolation of MDRO fr om a n y sit es o f the (including coloniser). The case must be an inpatient case. The case must be a “newly identified” case. b o d y “Newly identified” case include: MDROs identified for the first time during current hospital admission . Cases that have been identified with MDROs (infection / colonization) at your center but acquire ‘ new infection or colonization’ with different MDROs . NOTE: If more than one type of MDROs were isolated from the same patient, they should be counted separately. If a colonized case subsequently develops an infection, the case is counted as a new infection.

10. 4. DATA COLLECTION Infection Control Nurse (ICN) / Infection Control Personnel (ICP) shall collect data on MDRO on a daily basis from the laboratory. The ICN / ICP will liaise with staff in the relevant clinical area to ensure that the infection control practices are implemented. Where appropriate, the Clinical Microbiologist will inform the relevant Clinician of the result. Upon isolation of MDRO, the ICN / ICP should investigate and specify the type of infection based on the CDC / NHSN Surveillance Definition of Healthcare- Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting .

11. APPENDIX 1 - KEY TERMS Multidrug- resistant Organis m s (MDRO) MDRO are identified in microbiology laboratory and include organisms such as MRSA and other antibiotic resistant organisms. Multidrug- resistant Organisms (MDRO) MRSA - Staphylococcus aureus that tests oxacillin - or cefoxitin-resistant by standard susceptibility testing methods; or by a positive result for penicillin binding protein 2a (PBP2a) latex agglutination test or molecular testing for mecA gene. May also include positive results of specimens tested by other validated polymerase chain reaction (PCR) tests for MRSA. ESBL - are enzymes that mediate resistance to extended-spectrum (third generation) cephalosporins (e.g., ceftazidime, cefotaxime, and ceftriaxone) and monobactams (e.g., aztreonam). CLSI recommends confirmation of potential ESBL- producing isolates of K. pneumoniae or and E. coli by performing phenotypic testing using both cefotaxime and ceftazidime, alone and in combination with clavulanic acid.

12. APPENDIX 1 - KEY TERMS Multidrug- resistant Organis m s (MDRO) t hr e e or iii . MD R - Acinet o ba c t e r : Acin e tob a ct e r ba u m anii ( r e si s t ant o r in t er m ediat e ) to more antimicrobial classes iv. Carbapenem resistant Entrobacterales - Entrobacterales that meet the following criteria; Intermediate or resistant to imipenem, meropenem, ertapenem and doripenem by using MIC method, and confirmed by molecular method. v. Vancomycin-resistant Enterococci (VRE) – the resistance of an Enterococcus species to vancomycin according to the susceptibility breakpoints given by CLSI. If using disc diffusion method, plates should be held for full 24 hours for accurate detection of resistance. Organisms with intermediate zones should be tested by an MIC method.

13. APPENDIX 1 - KEY TERMS Colonization The p rese n ce of mi c ro or ganisms on s k in, m u c ou s m em br an e s, o pen wo u nds or excretions or secretions but is not causing adverse clinical signs or symptoms. Contamination Presence of microorganisms that do not multiply or cause clinical problems Implant A non-human-derived implantable foreign body (e.g., prosthetic heart valve, nonhuman vascular graft, mechanical heart, or hip prosthesis that is permanently placed in a patient during operative procedure and is not routinely manipulated for diagnostic or therapeutic purposes, screw, wires, and mesh that are left permanently are considered implants). Infection A positive culture of MDRO from a sterile site (blood, CSF, pleural fluid, peritoneal fluid) unless determined to be a contaminant. OR A positive culture of MDRO from a non-sterile site AND the presence of clinical signs and symptoms OR as determined by attending clinicians.

14. APPENDIX 2 - CLASSIFICATION OF INFECTION IN RELATIONS TO HEALTH CARE FACILITY

15. APPENDIX 2 - CLASSIFICATION OF INFECTION IN RELATIONS TO HEALTH CARE FACILITY

16. APPENDIX 2 - CLASSIFICATION OF INFECTION IN RELATIONS TO HEALTH CARE FACILITY

17. APPENDIX 2 - CLASSIFICATION OF INFECTION IN RELATIONS TO HEALTH CARE FACILITY

18. APPENDIX 2 - CLASSIFICATION OF INFECTION IN RELATIONS TO HEALTH CARE FACILITY

19. APPENDIX 2 - CLASSIFICATION OF INFECTION IN RELATIONS TO HEALTH CARE FACILITY

20. APPENDIX 2 - CLASSIFICATION OF INFECTION IN RELATIONS TO HEALTH CARE FACILITY

21. APPENDIX 2 - CLASSIFICATION OF INFECTION IN RELATIONS TO HEALTH CARE FACILITY Not Healthcare Associated (Community- associated MRSA) Community-associated MRSA cases are defined as meeting the following criteria No previous history of MRSA MRSA identified ≤48 hours after hospital admission No hospitalization in the previous 12 months No surgery or dialysis in the previous 12 months No residence in a long-term care facility in the previous 12 months No indwelling catheter or medical device (e.g., Foley’s catheter, IV line, tracheostomy, feeding tube)

22. APPENDIX 3 – MDRO SURVEILLANCE FORM (MDRO/MOH/2022 /1)

23. APPENDIX 4 - MDRO SURVEILLANCE LINE LISTING (MDRO/MOH/2022/2)

24. APPENDIX 5 - MDRO BACTERAEMIA SURVEILLANCE LINE LISTING (MDRO BACTERAEMIA/MOH/2022/3)

25. APPENDIX 6 – MONTHLY MDRO REPORTING FORM (MDRO/MOH/2022/4)

26. APPENDIX 7 –MDRO SURVEILLANCE REPORTING FORM (MDRO/MOH/2022/5)

27. APPENDIX 8 - MDRO BACTERAEMIA SURVEILLANCE REPORTING FORM (MDRO BACTERAEMIA/MOH/2022/6)

28. APPENDIX 9 - MDRO SURVEILLANCE FLOW CHART

29. Scenario Examples Scenario 1: Mr. Ali has been transferred from Hospital A to Hospital B for further treatment. A urine culture was taken within less than 48 hours of the patient being in the ward at Hospital B, and the result of the urine culture is positive for Carbapenem- Resistant Enterobacterales (CRE). Should Mr. Ali's case be notified in the MDRO surveillance of Hospital A or B?

30. Answer: Mr. Ali's case needs to be entered into the MDRO data of Hospital B and classified as Healthcare Associated (HA), Another Healthcare Facility, as the case meets the criteria for such classification.

31. Scenario Examples Scenario 2: Ms. Muna was admitted to the medical ward on 1/12/2022. Blood Culture and Sensitivity (C&S) was taken within 48 hours of Ms. Muna's admission to the ward, and the result is positive for MRSA. According to records, Ms. Muna had just been discharged from the Nephro ward at the same hospital a week ago. The Blood C&S result at that time was also positive for MRSA. Is this case categorized as Healthcare Associated (HA) MRSA infection?

32. Answer: Yes, because it meets the criteria for Healthcare Associated, Own Hospital and does not meet the criteria for Community Associated MRSA. This case only needs to be reported once on 1/12/2022.

33. Scenario Examples Scenario 3: Mr. Tan is a bedridden patient who was admitted to the hospital. Mr. Tan's tracheal aspirate sample in July 2022 tested positive for ESBL Klebsiella pneumoniae, and it is a colonizer. In August 2022, Mr. Tan was admitted to the ward, and the urine Culture and Sensitivity (C&S) sample was positive for ESBL Klebsiella pneumoniae, indicating colonization. On September 22, Mr. Tan developed a bloodstream infection with ESBL Klebsiella pneumoniae originating from an infected gluteal pressure sore. Should this case be reported in the MDRO surveillance for July? Should this case be reported in the MDRO surveillance for August? Should this case be reported in the MDRO surveillance for September?

34. Answer: Needs to be included in the surveillance for July. Not included in the August surveillance because one of the exclusion criteria is cases readmitted with the same MDROs within one year. Needs to be included in the surveillance for September because it involves a bloodstream infection.

35. Scenario Examples Scenario 4: Mr. Wong was admitted to the ward in July 2022, and the Urine Culture and Sensitivity (C&S) result at that time was positive for ESBL Klebsiella pneumoniae (colonizer). Mr. Wong was discharged with a Foley's catheter due to acute urinary retention secondary to benign prostatic hyperplasia (BPH). Mr. Wong was readmitted to the ward again in August 2022 with symptoms of urinary tract infection (UTI). The Urine C&S result was positive for ESBL Klebsiella pneumoniae, and the diagnosis indicated catheter-associated UTI (CAUTI). The sample was taken within 48 hours after hospital admission. Should this case be reported in the MDRO surveillance for August 2022?

36. Answer: Yes. This case should be reported in both months (July and August 2022) and needs to be classified as Healthcare Associated, Own Hospital as a colonised case which subsequently develops an infection is counted as a new infection.

37. Scenario Examples Scenario 5: If a rectal swab conducted for the purpose of CRE screening for contacts of an index patient with CRE is positive, should this case be reported in the MDRO surveillance?

38. Answer: Yes, because contact screening cultures that were done for contacts of index patient with MDROs are included in the MDRO surveillance.

39. Scenario Examples Scenario 6: A rectal swab was conducted to screen for CRE in a patient transferred from the general ward to the ICU, and this patient is NOT a contact of any CRE index patient. The result of the rectal swab is positive for CRE. Should this case be reported in the MDRO surveillance?

40. Answer: Not included in the MDRO surveillance because it falls under the exclusion criteria - Screening cultures that were done NOT for contacts of index patient with MDROs.

41. Scenario Examples Scenario 7: Mrs. Wan attended the outpatient clinic one month after undergoing a Lower Segment Caesarean Section (LSCS) surgery and experienced an infection at the surgical wound site. A wound swab was taken, and the result indicated a positive finding for ESBL Klebsiella pneumoniae. However, Mrs. Wan was not admitted to the ward and only received treatment at the clinic as an outpatient. Does Mrs. Wan's case need to be reported in the MDRO surveillance?

42. Answer: Not necessary, as it is a case from an outpatient clinic, which is considered one of the exclusion criteria for MDRO surveillance.

43. Scenario Examples Scenario 8: Mr. Manan is confirmed to have urinary tract infection associated with nephrolithiasis, and the Urine Culture and Sensitivity (C&S) result on January 1, 2022, is positive for ESBL Escherichia coli. On January 10, 2022, Mr. Manan's condition deteriorates, and the Blood Culture and Sensitivity (C&S) result is positive for ESBL Escherichia coli (ESBL E. coli bloodstream infection secondary to UTI). Should this case be notified for both conditions (January 1 and January 10)?

44. Answer: Y e s . B o th occas i ons nee d to b e notifi e d becau s e secondary bloodstrea m infection should be reported as a newly identified case.

45. Scenario Examples Scenario 9: Ms. Sheril is confirmed to have a urinary tract infection associated with nephrolithiasis, and the Urine Culture and Sensitivity (C&S) result on January 1, 2022, is positive for ESBL Escherichia coli. On the same day, Ms. Sheril developed a fever, and the Blood Culture and Sensitivity (C&S) result is positive for ESBL Escherichia coli (ESBL E. coli bloodstream infection secondary to UTI). Should this case be notified on two separate notification forms?

46. Answer: No. Only notify the results of the Blood Culture and Sensitivity (C&S) because it occurred on the same day.

47. Scenario Examples Scenario 10: Ms. Wong was admitted to the ward on June 7, 2022. The Urine Culture and Sensitivity (C&S) result is positive for ESBL E. Coli, and the Blood Culture and Sensitivity (C&S) result is positive for MRSA. Should both of the MDRO organisms be reported?

48. Answer: Yes, because if more than one type of MDROs are isolated from the same patient, they should be counted separately.

49. INFECTION CONTROL

50. THANK YOU Infection Control Unit, Medical Care Quality Section, Medical Development Division, Ministry of Health Malaysia Credit to: