APPROACH TO MULTIDRUG RESISTANT ORGANISMS

exp date isn't null, but text field is

Overview

Colonization and infection with Multidrug resistant organisms (MDRO) are on the rise with increased morbidity, mortality and costs. With increased use of antibiotics and hence, enhanced selective antimicrobial pressure multi- and extensively drug-resistant pathogens (e.g. methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter baumannii, etc.) are increasing in prevalence.

Restricted and judicious antibiotics use, usually implemented as part of AMSP (Antimicrobial stewardship programme) and guided by local antibiogram, along with infection control measures prevent the emergence and spread of MDRO.

Antibiogram use

Monitoring of clinical microbiology isolates resulting from tests done as a part of routine clinical care helps to understand the common pathogens in various specimens as well as to generate an overall profile of antimicrobial susceptibility of a specific microorganism. The development of such antibiograms can help to detect the emergence of new MDROs not previously detected and also prepare facility-specific summary antimicrobial susceptibility reports which provide clinicians with information to guide antimicrobial prescribing practices. Antibiograms, the simplest form of MDRO surveillance, are the easiest method to prepare facility-specific antimicrobial guidelines and thus an essential tool to fight against MDROs.

Fluoroquinolones and linezolid use

Because of the high prevalence of Tuberculosis and increasing prevalence of MDR-TB in Nepal, it’s advisable to reserve Fluoroquinolones and Linezolid and limit their use for other indications.

Combination Antibiotics with Polymyxins

When a polymyxin (Polymyxin B or Colistin) is being used to treat MDRO, it should be used in combination with a second active agent. The second active agent could be Meropenem (especially if MIC to meropenem is ≤ 8 mcg/mL) or Tigecycline (especially for GI tract and pulmonary infections) or an aminoglycoside. The rationale for using two or more agents when a polymyxin-based regimen is being used includes reduced mortality with combination therapy and the concern for emergence of resistance during monotherapy.

Approach

  • Good hand hygiene compliance.
  • Contact precautions for patients who harbor epidemiologically relevant drug-resistant organisms.
  • Minimizing unnecessary hospitalization and interventions.
  • Adequate and standardized approaches to environmental cleaning and disinfection.
  • Intensive infection control interventions to reduce colonization pressure – e.g. cohorting with dedicated staff, chlorhexidine bathing, selective decontamination, active surveillance for specific pathogens, reduction of catheterization utilization, etc.
  • Restricted and judicious antimicrobial utilization – e.g. institutional AMSP, Infection Prevention and Control (IPC)