Multidrug Resistant Organism Infectious Disorders

COORDINATING CARE FOR PATIENTS WITH MULTIDRUG RESISTANT ORGANISM INFECTIOUS DISORDERS CHAPTER 21 AUTUMN EASTMAN, MSN RN 3/26/25  OBJECTIVES Define multidrug resistance and the antibiotic stewardship program Describe risk factors...

COORDINATING CARE FOR PATIENTS WITH MULTIDRUG RESISTANT ORGANISM INFECTIOUS DISORDERS CHAPTER 21 AUTUMN EASTMAN, MSN RN 3/26/25  OBJECTIVES Define multidrug resistance and the antibiotic stewardship program Describe risk factors for each MDRO Describe how each MDRO is transmitted Apply nursing strategies to prevent the occurrence, transmission, and potential of worsened outcomes for patients at risk and colonized for common MDR organisms Apply safe medication practices in  ROUTES OF TRANSMISSION CONTACT AIRBORNE VEHICLE VECTOR  CONTACT TRANSMISSION Occurs when a person or object comes in contact with a pathogen Examples: Touching a doorknob, pressing an elevator button, shaking hands  AIRBORNE TRANSMISSION Occurs when pathogens are carried through the air Examples: Sneezing, coughing, Influenza, TB  VEHICLE TRANSMISSION  An indirect mode of transmission  Occurs when a disease carrying agent touches a person’s body or is ingested  Examples: Water contamination, food, medications, Hepatitis A  VECTOR BORNE TRANSMISSION An indirect mode of transmission that occurs when a vector its or infects a person Examples: Birds, Insects, Lyme Disease, Malaria, West Nile Virus WHAT ARE MULTIDRUG RESISTANT ORGANISMS? (MDRO’S) Microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents WHY DOES THIS MATTER? 1. MDRO infections have clinical manifestations that are similar to infections caused by susceptible pathogens 2. Options for treating patients with these infections are often extremely limited. 3. Increased lengths of stay, costs, and mortality also have been associated with MDROs  METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) Most common multi-drug resistant pathogen The result of decades of unnecessary antibiotic use Currently resistant to all beta lactam antibiotics (Penicillin's, cephalosporins and carbapenems) Risk Factors 1. Hospitalization in last 12 months 2. Soft tissue infection 3. Hospitalization in intensive care 4. Residing in a long-term care facility 5. Weakened or immature immune system (young children, older adults, HIV/AIDS, cancer, chronic conditions) * Consider what invasive procedures these patients may have done (Catheters, IV lines, long term antibiotic use) * Click icon to add picture MRSA CONTINUED  Pathophysiology  contact with pathogen  Lives on surfaces and humans for days to weeks  When a person is colonized with MRSA, the pathogen can easily be transferred to the skin and other body areas  Example: MRSA colonized in the nose, Person wipes their nose with their hand and touches open skin, MRSA would transfer to the wound  MRSA CLINICAL MANIFESTATIONS  Serious infections  Pneumonia  Skin and soft tissue infections  Surgical site infections  Bloodstream infections  What are our cardinal signs of inflammation? MRSA COMPLICATIONS Increased morbidity and mortality  Longer lengths of stay, higher hospital costs  High risk of death Osteomyelitis Toxic shock syndrome Multisystem organ failure  VANCOMYCIN RESISTANT ENTEROCOCCI (VRE) 1. Enterococci are bacteria that normally live in the gastrointestinal tract, the female genital tract and are also found in the environment in soil, water, and food. 2. Bacteria that have evolved and become resistant to vancomycin 3. Higher incidence in larger teaching hospitals, secondary to increased severity of illness 4. Hand hygiene compliance affects prevalence of VRE 5. Antibiotic stewardship is associated with lower rates 6. Reducing use of vancomycin and cephalosporins have decreased prevalence in the US  VRE RISK FACTORS  Prolonged hospital stays  Immunosuppressed (Patients in ICUs, transplant patients, cancer patients)  Prolonged exposure to antibiotics  Invasive procedures and devices  Similar to MRSA  VRE PATHOPHYSIOLOGY Direct contact from skin or patient equipment Examples: Hands, unclean equipment Can remain on surfaces for up to 2 months Large emphasis on prevention WHY?  Difficult to control due to antibiotic use increases microbial load of VRE Treatment options are limited Polypharmacological approach is often necessary VRE CLINICAL MANIFESTATIONS  Urinary tract infections  Signs and symptoms: back pain, dysuria, urinary urgency, fever  Bacteremia  Signs and symptoms: tachycardia, hypotension, fever, think sepsis  Wound infection  Signs and symptoms: red, warm to touch, purulent drainage  Peritonitis (Intra abdominal and pelvic wound infections)  Signs and symptoms: depending on location and severity VRE COMPLICATIONS 1. Vancomycin resistant S.aureus 2. Prolonged hospital stay 3. Prolonged antibiotic therapy 4. Higher mortality 5. Increased cost of hospitalization 6. Osteomyelitis, pneumonia, sepsis, endocarditis  Most common cause of antibiotic associated diarrhea 12% of all hospital acquired infections CLOSTRIDIOIDES 4-15% of healthy individuals are colonized DIFFICILE (C DIFF) with C. diff, and 3% to 21% of patients on admission to hospitals are colonized with C. diff without showing symptoms of the disease C DIFF RISK FACTORS  Use of antimicrobials  Clindamycin, cephalosporins, aminoglycosides, penicillins, and fluoroquinolones  WHY? Suppress the normal bowel flora  Duration of hospitalization  GI Surgery  Immunosuppression  Nasogastric tubes  WHY? Prolonged periods of no oral intake, impaired bowel motility  Use of acid-suppressing medications  H2 blockers and proton pump inhibitors C DIFF PATHOPHYSIOLOGY  Spore-forming bacteria  Resistant to many types of disinfectants, heat, and dryness  Live on surfaces for months  In skin folds, on hands of healthcare workers  Almost exclusively found in healthcare settings  Hands of healthcare workers are primary source  Oral-fecal transmission  A patient with C diff must be put on contact-isolation precautions  C DIFF MAJOR COMPLICATIONS 1. Volume depletion 2. Renal insufficiency 3. Electrolyte imbalance 4. Hyperalbuminemia 5. Peritonitis 6. Paralytic Ileus 7. Toxic Megacolon 8. Perforation of colon 9. Sepsis 10.Death  C DIFF AND SKIN BREAKDOWN Excessive moisture Alkaline pH Colonization with microorganisms Friction Proper perineal cleansing is imperative Barrier creams/ointments Fecal management systems  Resistant to more than three classes of antibiotics The emergence of MDR Acinetobacter is due to the use of broad- ACINETOBACTER spectrum antimicrobials and the transmission of strains among patients. BAUMANNII 35% increase in Carbapenem-resistant Acinetobacter, with a hospital-onset of 78%. Causes an increase in morbidity and mortality as well as an increased length of stay in that setting. The incidence of Acinetobacter infections is highest in ICUs with complex patients in the ICU having the highest risk. Typically colonized in the skin, throat, rectum, and urinary tract This organism has the ability to survive for weeks to months on both dry and moist surfaces  Recent surgery Central venous catheters, tracheostomy, mechanical ventilation Exposure to antimicrobial agents  especially fluroquinolone and carbapenems RISK FACTORS Prior colonization with MRSA Hemodyalisis Malignancy Poor glucocorticoid therapy **Vascular catheters and respiratory tract are most frequent source**  Dependent on colonization/Infection Site  Respiratory tract, GI tract, blood, pleural CLINICAL fluid, peritoneum, urinary tract, surgical MANIFESTATIONS wounds, CNS, skin, and eyes Most common  ventilator associated pneumonia and bloodstream infections CARBAPENEM RESISTANT ENTEROBACTERIACEAE (CRE)  In 2018, CDC reported 9,300 CRE Healthcare associated infections in the US  50% of patients who develop bloodstream infections from CRE die from them  CDC has labeled CRE as urgent concern  Can cause infections in both hospital and community setting  Healthy people are typically not at risk  Carbapenem abx are typically used as a last resort for treating severe infections, so these organisms are especially dangerous  high mortality  CRE RISK FACTORS 1. Older adults 2. Hospitalization 3. Resident of long-term care facilities 4. Diabetes 5. Heart Disease 6. Renal Disease 7. Indwelling devices (catheters, central venous lines, feeding tubes)  CRE PATHOPHYSIOLOGY  Direct contact  Infected or colonized people  Wounds  Stool  Enterobacteriaceae include Klebsiella and E. Coli  These organisms are usually found in the intestines and if contained they are harmless  Outside of the intestines, they can cause serious infections  UTIs, bloodstream, wound, pneumonia  CRE CLINICAL MANIFESTATIONS Fever Chills Signs of sepsis Vary depending on location of infection  MANAGEMENT OF MULTIDRUG RESISTANT ORGANISMS Diagnosis Surveillance  some facilities perform screening on any patient admitted Bacterial cultures Risk assessment tools Treatment Hand hygiene  best treatment begins with prevention Alcohol based hand rubs NOT EFFECTIVE AGAINST C DIFF Isolation Contact isolation precautions Medications NURSING ASSESSMENT  Vital signs  Pain Assessment  Skin turgor  Urine output  Wound or surgical site  WBC Count  Lab work  Bowel movement frequency/consistency  Skin integrity NURSING ACTIONS AND PRIORITIES  Hand hygiene  Isolation precautions  Administer antibiotics  Administer fever reducer  Administer pain medications  Administer IV fluids  Supplemental oxygen  Chest physiotherapy  Encourage early mobilization Click icon to add picture COMMONLY USED ANTIBIOTICS MRSA  Vancomycin  Serum levels and trough levels must be monitored to avoid toxic doses and maintain therapeutic levels  Can cause nephrotoxicity and ototoxicity, consider patients with renal failure  Weekly BUN and serum creatinine levels Other antibiotic options include Linezolid (Zyvox) Daptomycin (Cubicin) Tigecycline (Tygacil) Clindamycin (Cleocin) Sulfamethoxazole-trimethoprim (Bactrim) Click icon to add picture COMMONLY USED ANTIBIOTICS VRE  Difficult to treat and often require multiple antibiotics due to resistance to penicillin and ampicillin  Susceptibility testing is recommended  Quinupristin-dalfopristin (Synervid)  can be caustic to veins, PICC placement is often recommended if long term use is required  Linezolid  Daptomycin  Chloramphenicol  successfully treated VRE for many years but should not be a first line agent due to high incidence of toxicity Click icon to add picture COMMONLY USED MEDICATIONS C. DIFF  Before treatment can begin, the suspected causative antibiotic must be stopped  WHY?  Use of peristaltic agents should be avoided  WHY?  Oral vancomycin is 1st line agent for initial episode of severe C. diff  IV or Oral Metronidazole  Fidaxomicin (Dificid)  Monoclonal antibody Bezlotoxumab  Probiotics  Fecal Microbiota transplantation Click icon to add picture COMMONLY USED MEDICATIONS ACINETOBACTER  Mild to severe cases  Sulbactams combined with ampicillin- sulbactam (Unasyn)  Tetracyclines (Minocycline, Doxycycline)  Carbapenems (Imipenem, meropenem)  Getting increasingly more challenging to treat/dose due to increased carbapenem resistance Click icon to add picture COMMONLY USED MEDICATIONS CRE  Treatment is based on susceptibility  Limited options but include:  Third generation cephalosporins, meropenems, polymyxib, plazomicin  PATIENT TEACHING Contact precautions Teach patient and visitors the importance of wearing gowns and gloves when entering the room and removing the gowns and gloves when exiting the patient’s room; also teach them the importance of performing hand hygiene after removing the gown and gloves. Take medications as prescribed Finishing course of antibiotics  WHY? Clinical manifestations of infection Sun protection Tetracycline antibiotics that are used can cause sun sensitivities, avoid prolonged sun exposure, wear sunscreen, appropriate clothing for weather  NURSING CONSIDERATIONS  Risk for deficient fluid volume  Ineffective airway clearance  Alteration in comfort  Risk for skin breakdown  Impaired tissue integrity  Impaired urinary elimination  Acute pain  ANTIBIOTIC STEWARDSHIP “Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance.”