2013 Spring Meeting Antibiotic Interest Group presentations

Report
of MultiDrugResistant
Organisms
The
Alan D. Junkins, PhD, D(ABMM)
Louisville, KY
Sponsored by an
educational grant from
You know that
Pseudomonas aeruginosa
from Mr. Jones in 5F? Is
that an MDRO?
Why do you want
to know?
Why are you
asking me?
How should I
know?
Why do you want
to know?
Why do you want to know?
• Your own internal monitoring
– “We’ve had a 35% increase in MRSA isolates this
year.”
• For infection control purposes
– “All patients with MDR GNB are placed in contact
precautions.”
• Reporting to authorities
– “We have to report all MDROs to the state.”
Why do you want to know?
• Your own internal monitoring
– “We’ve had a 35% increase in MRSA isolates this
year.”
• For infection control purposes
Who
defines
MDRO?
– “All patients with MDR GNB are placed in contact
precautions.”
• Reporting to authoritiesYou do,
Or whomever
– “We have to report
all MDROs toyou’re
the state.
producing the data for
Why do you want to know?
• Your own internal monitoring
– “We’ve had a 35% increase in MRSA isolates this
year.”
• For infection control purposes
– “All patients with MDR GNB are placed in contact
precautions.”
• Reporting to authorities
Who
defines MDRO?
– “We have to report all MDROs to the state.
Your infection control team
Why do you want to know?
• Your own internal Who
monitoring
defines
MDRO?
– “We’ve had a 35% increase in MRSA isolates this
year.”
CDC, State, Parent
• For infection controlNHSN,
purposes
Company
– “All patients with MDR GNB are placed in contact
precautions.”
• Reporting to authorities
– “We have to report all MDROs to the state.”
Hence, the problem…
Different people doing the defining…
for different reasons…
…leads to different definitions.
I know one when I see one…
…well, maybe not.
The Simplest Approach
The Not Quite As Simple But Now The Closest
Thing We Have to Universally Accepted Approach
Resistant to > 1 drug
Non-susceptible to >2 classes of drugs
XDR and PDR
Non-susceptible to at least 1 drug in
all but two or fewer classes
Non-susceptible to all
agents in all classes
What is a “class” of drugs?
Beta-lactams
What is a “class” of drugs?
Penicillins
Cephalosporins
Monobactams
Carbapenems
What is a “class” of drugs?
Aminopenicillins
1st gen. Cephalosporins
Ureidopenicillins
2nd gen. Cephalosporins
Carboxypenicillins
3rd gen. Cephalosporins
ß-lactamase resistant
penicillins
4th gen. Cephalosporins
5th gen. Cephalosporins
ß-lactamase inhibitor
combinations
Cefamycins
Monobactams
Carbapenems
What is resistance to a class?
Gentamicin
Tobramycin
Amikacin
Resistant to
this class?
Bug A
R
R
R
Bug B
R
R
S
Bug C
R
S
S
Bug D
I
S
S
What about intrinsic resistances?
• Should intrinsic resistance count toward
number of classes showing resistance?
• Typically chromosomally encoded; those
genetic determinants are not easily passed on
to other bacteria
• But still can be bad boys – bad infections, bugs
can be transmitted to others, hard to treat
If we include intrinsic resistances in our definition, then every
single Acinetobacter baumannii, Burkholderia cepacia,
Pseudomonas aeruginosa, and Stenotrophomonas
maltophilia we isolate would be considered MDRO.
If we include intrinsic resistances in our definition, then every
single Morganella, Proteus, Providencia, and Serratia
marcescens we isolate would be considered MDRO.
I’ll refer to
this later as
the “GBGX”
paper.
22 drugs in 17 classes
MDR – NS to at
least one drug in at
least 3 classes
XDR – NS to at least
one drug in all but
2 or fewer classes
PDR – NS to all
drugs in all classes
22 drugs in 17 classes
14 drugs in 13 classes
MDR – NS to at
least one drug in at
least 3 classes
XDR – NS to at least
one drug in all but
2 or fewer classes
PDR – NS to all
drugs in all classes
Standardization, but is it practical?
Organism
What they suggest
What’s on our panel
Staphylococcus aureus
22 drugs in 17 classes
14 drugs in 13 classes
Enterococcus
17 drugs in 11 classes
10 drugs in 8 classes
Enterobacteriaceae
32 drugs in 17 classes
23 drugs in 14 classes
Pseudomonas aeruginosa
17 drugs in 8 classes
11 drugs in 6 classes
Acinetobacter
22 drugs in 9 classes
14 drugs in 8 classes
MDR – NS to at least one drug in at least 3 classes
XDR – NS to at least one drug in all but 2 or fewer classes
PDR – NS to all drugs in all classes
Authors recommend additional
designations:
“Possible XDR”
“Possible PDR”
We’ll call this
one the “CDC”
paper.
Based on 2008 SHEA/HICPAC Position
Paper published in Inf Control & Hosp
Epidemiol, October 2008, vol. 29, no. 10
http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf, January 2013
MDRO Definitions
Resistant to oxacillin, methicillin, or
cefoxitin, or positive by an FDA-approved
test for mecA on isolated colonies or in
specimens
Not a MRSA
http://www.cdc.gov/nhsn/PDFs/pscMan
ual/12pscMDRO_CDADcurrent.pdf,
January 2013
MDRO Definitions
Any Enterococcus resistant to vancomycin
or positive by an FDA-approved test for
VRE
Any Klebsiella non-susceptible to
ceftriaxone, cefotaxime, ceftazidime, or
cefepime***
***Based on new breakpoints
http://www.cdc.gov/nhsn/PDFs/pscMan
ual/12pscMDRO_CDADcurrent.pdf,
January 2013
MDRO Definitions
Non-susceptible to imipenem,
meropenem, or doripenem***, or
positive by a test for carbapenemase
***Based on new breakpoints
http://www.cdc.gov/nhsn/PDFs/pscMan
ual/12pscMDRO_CDADcurrent.pdf,
January 2013
MDRO Definitions
http://www.cdc.gov/nhsn/PDFs/pscMan
ual/12pscMDRO_CDADcurrent.pdf,
January 2013
Call this one
the “CRE
Toolkit”
Based on new breakpoints
Back to CRE
http://www.cdc.gov/hai/organisms/cre/cre-toolkit/
But maybe not so straightforward…
http://www.cdc.gov/hai/organisms/cre/cre-toolkit/
How many CRE at Norton*?
(since January 1, 2010)
True Modified Hodge Positive
Standard definition from CDC’s
“CRE Toolkit”
Take away imipenem-NS Proteus,
Providencia, Morganella
Include ertapenem NS isolates
*We are still using the “old” cephalosporin and carbapenem breakpoints.
Mandatory Reporting
• Which definition to use?
– Labs using old breakpoints
– Labs using new breakpoints
• Infections only, or include
colonization?
– Mandatory surveillance?
– Which method?
• CDC method
• Chromogenic media
What We’ve Done
• Certain organisms are designated in microbiology laboratory reports
as MDROs.
• The Microbiology Laboratory makes this determination on the basis
of full susceptibility results from the MicroScan and supplemental
testing if necessary.
• The chief intent is infection control. All patients infected with an
isolate reported as an MDRO are put into contact precautions.
• We continue to use pre-2009 CLSI breakpoints for cephalosporins
and carbapenems with supplemental testing for beta-lactamases as
necessary.
• We generally do not do surveillance cultures to detect colonization,
with the exception of weekly MRSA cultures in the NICU.
Our MDRO Definitions
• MRSA – by oxacillin or cefoxitin MIC or by
growth on chromogenic medium
• VRE – by vancomycin MIC; E. faecalis and E.
faecium only
• E. coli, Klebsiella, and Proteus mirabilis that
produces ESBL enzymes
• Certain Enterobacteriaceae that produce
plasmid-encoded AmpC enzymes
Our MDRO Definitions
Our MDRO Definitions
Our MDRO Definitions
What about other bugs?
Is this an MDRO?
Amox/Clav
R
Linezolid
S
Ceftriaxone
R
Oxacillin
R
Clindamycin
S
Rifampin
S
Cefazolin
R
Trim/Sulfa
S
Daptomycin
S
Tetracycline
S
Erythromycin
S
Vancomycin
S
Gentamicin
S
Levofloxacin
S
GBGX:
CDC:
Is this an MDRO?
Amox/Clav
S
Linezolid
S
Ceftriaxone
S
Oxacillin
S
Clindamycin
R
Rifampin
S
Cefazolin
S
Trim/Sulfa
S
Daptomycin
S
Tetracycline
R
Erythromycin
R
Vancomycin
S
Gentamicin
S
Levofloxacin
R
GBGX:
CDC:
Is this an MDRO?
Ampicillin
R
Linezolid
R
Daptomycin
S
Penicillin
R
Nitrofurantoin
I
Tetracycline
R
Gent. Synergy
S
Vancomycin
S
Levofloxacin
R
GBGX:
CDC:
Is this an MDRO?
Ampicillin
S
Linezolid
S
Daptomycin
S
Synercid
S
Nitrofurantoin
S
Tetracycline
S
Gent. Synergy
S
Vancomycin
R
Levofloxacin
S
GBGX:
CDC:
Is this an MDRO?
Amikacin
R
Gentamicin
R
Amp/Sulbactam
I
Levofloxacin
R
Ceftazidime
R
Meropenem
R
Cefotaxime
R
Tetracycline
R
Ciprofloxacin
R
Trim/Sulfa
R
Cefepime
R
Tigecycline
R
Colistin
S
Tobramycin
R
GBGX:
CDC:
Is this an MDRO?
Amikacin
S
Gentamicin
S
Amp/Sulbactam
S
Levofloxacin
R
Ceftriaxone
I
Meropenem
R
Ceftazidime
S
Tetracycline
R
Cefotaxime
I
Trim/Sulfa
R
Ciprofloxacin
R
Tobramycin
S
Cefepime
S
GBGX:
CDC:
Is this an MDRO?
Amikacin
R
Imipenem
S
Aztreonam
R
Levofloxacin
S
Ceftriaxone
R
Meropenem
S
Ceftazidime
R
Pip/Tazo
R
Cefotaxime
R
Piperacillin
R
Ciprofloxacin
S
Trim/Sulfa
R
Cefepime
R
Tetracycline
S
Gentamicin
R
Tobramycin
R
GBGX:
CDC:
Is this an MDRO?
Amikacin
S
Imipenem
S
Aztreonam
R
Levofloxacin
R
Ceftazidime
S
Meropenem
S
Ciprofloxacin
R
Pip/Tazo
S
Cefepime
S
Piperacillin
S
Gentamicin
I
Tobramcyin
S
GBGX:
CDC:
Is this an MDRO?
Old breakpoints
ESBL positive
Amp/Sulbactam
S
Ertapenem
S
Amikacin
S
Imipenem
S
Ampicillin
R*
Levofloxacin
S
Ceftriaxone
R*
Meropenem
S
Ceftazidime
R*
Pip/Tazo
S
Cefazolin
R*
Trim/Sulfa
S
Ciprofloxacin
S
Tetracycline
S
Cefepime
R*
Tobramycin
S
GBGX:
CDC:
Is this an MDRO?
Amp/Sulbactam
R
Ertapenem
S
Amikacin
S
Imipenem
S
Ampicillin
R
Levofloxacin
S
Ceftriaxone
S
Meropenem
S
Ceftazidime
S
Pip/Tazo
S
Cefazolin
R
Trim/Sulfa
S
Ciprofloxacin
S
Tetracycline
S
Cefepime
S
Tobramycin
S
GBGX:
CDC:
Is this a CRE?
Amp/Sulbactam
R
Cefazolin
R
Ampicillin
R
Cefepime
S
Amox/Clav
R
Cefuroxime
R
Aztreonam
R
Ertapenem
R
Ceftriaxone
R
Imipenem
I
Ceftazidime
R
Meropenem
S
Cefotaxime
R
Piperacillin
R
Cefoxitin
R
Pip/Tazo
I
CDC:
CRE Toolkit:
Is this a CRE?
New breakpoints
Amp/Sulbactam
R
Cefazolin
R
Ampicillin
R
Cefepime
S
Amox/Clav
R
Cefuroxime
R
Aztreonam
R
Ertapenem
R
Ceftriaxone
R
Imipenem
I
Ceftazidime
R
Meropenem
S
Cefotaxime
R
Piperacillin
R
Cefoxitin
R
Pip/Tazo
I
CDC:
CRE Toolkit:
Is this a CRE?
New breakpoints
Amp/Sulbactam
R
Cefazolin
R
Ampicillin
R
Cefepime
S
Amox/Clav
R
Cefuroxime
R
Aztreonam
S
Ertapenem
S
Ceftriaxone
S
Imipenem
I
Ceftazidime
S
Meropenem
S
Cefotaxime
S
Piperacillin
R
Cefoxitin
R
Pip/Tazo
S
CDC:
CRE Toolkit:
Is this a CRE?
Amp/Sulbactam
R
Cefazolin
R
Ampicillin
R
Cefepime
S
Amox/Clav
R
Cefuroxime
R
Aztreonam
R
Ertapenem
I
Ceftriaxone
R
Imipenem
S
Ceftazidime
R
Meropenem
S
Cefotaxime
R
Piperacillin
R
Cefoxitin
R
Pip/Tazo
I
CDC:
CRE Toolkit:
So what to do?
• Will the lab designate isolates as MDRO?
• Why? What’s your purpose? How will the data
be shared?
• Create meaningful definitions that fit your
purpose.
• Continue to follow good selective reporting, but
include non-reported drugs in determining MDRO
status.
• Make determination of MDRO status as easy as
possible. Automate if possible.
And thanks to Siemens for their sponsorship of this program.

similar documents