Are ESBLs the New MRSA

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Are ESBLs the New MRSA??

• Eleri Davies
• Consultant Microbiologist NPHS Microbiology,
  Cardiff
• Infection Control Doctor, Velindre NHS Trust

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ESBLs Infection Control

• ESBL specific Infection Control Policies?
• Should we screen for ESBLs?
• Outbreak Management
• Special considerations for ESBLs?
• Surveillance for ESBLs?
• Conclusions

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ESBLs Infection Control

• ESBL specific Infection Control Policies?

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Infection Control Policies

• No UK or US national guidance specific to ESBLs.
• Literature search
• Mainly outbreak reports
• Healthcare Infection Control Practices Advisory
  Committee draft guidance (isolation precautions)
  Control of MDROs
• Survey of IC Team practices in Canada

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Outbreak Reports

• Contact and isolation precautions
• Strict adherence to Infection Control standards
• Judicious use of 3rd generation cephalosporins.
• Pena et al, AAC 19984253-58
• Rebuck et al, CID 2000311368-1372

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Outbreak Reports

• Macrae et al, JHI,200149183-192
• Admission screening to neonatal unit
• Isolation
• Ward and hand hygiene
• Quale et al, CID, 200235834-841
• Association noted with cephalosporin usage
• BUT fiscal constraints prohibits aggressive
  infection control and antibiotic usage policies!

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• Sturenberg Mack, Journal of Infection.
  200347273-295. Review
• Isolation and contact precautions
• Tagging of records
• Limit movement of patients
• Private room / cohorting
• Antibiotic utilisation policy
• Above modification of CDC guideline for isolation
  precautions in hospitals 1996.

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Guideline for Isolation Precautions
Recommendations of the Healthcare Infection
Control Practices Advisory Committee.Infection
Control and Hospital Epidemiology 19961753-80
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On CDSC website for consultation June 10th. 04
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Draft revised guidelines for isolation precautions

• Generic guidance for Multi Drug Resistant
  Organisms (MDROs)
• Administrative Measures / Adherence monitoring.
• Education
• Judicious antimicrobial use
• Surveillance
• Infection control precautions to prevent
  transmission.
• Environmental measures
• Decolonisation

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Draft revised guidelines for isolation precautions

• Standard measures for all healthcare settings
• Increased measures recommended if
• Transmission of MDROs continuing despite use of
  routine control measures.
• If prevalence of MDROs above institutional
  thresholds.
• If a novel MDRO is emerging within the facility.

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Clash of the Guidelines The David Goliath of
guidelines APIC conference June 04
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Variation in approach to ESBL Enterobacteriaceae
among infection control practitioners Results of
an Ontario wide survey (n23)

• Isolate of E.coli ESBL
• 70 contact precautions \- isolation
• 26 no specific interventions / handwashing
• Approach would not differ for
• cipro R vs cipro S
• E.coli vs Klebsiella sp.
• Urine vs sputum vs blood
• Ward vs ICU

Canada Communicable Disease Report 2002 vol. 28-15
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Variation in approach to ESBL Enterobacteriaceae
among infection control practitioners Results of
an Ontario wide survey (n23)

• Discontinuation of precautions
• 67 based on culture results of site rectal
  swab.
• 80 3 x negatives
• 50 weekly intervals between cultures
• 33 discontinue on individualised basis
• ESBL vs AmpC resistance
• 30 no contact precautions / isolation for either
• 30 only for ESBL
• 39 CP / isolation for both

Canada Communicable Disease Report 2002 vol.
28-15
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ESBLs Infection Control

• Should we screen for ESBLs?

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Search Destroy?

• Detection of ESBLs
• ? Size of community reservoir
• Isolation facilities
• Failed with MRSA (UK)

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• Rectal swabs / faeces for all admissions to
  specialist units?
• Macrae et al, JHI,200149183-192
• Screening for carriage during outbreak
  management
• Pena et al, AAC 19984253-58
• Shannon et al, JHI 199839291-300
• Macrae et al, JHI,200149183-192
• Stewart Lessing, JHI 19994171-78
• Environmental screening
• Gaillot et al, JCM,1998361357-1360
• Cotton et al, JHI, 20004413-17
• Macrae et al, JHI,200149183-192
• Gastmeier et al, AJIC,200331424-430

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Screening on specialist units

• Sensitivity of method
• Laboratory costs
• Preventative measures
• Isolation
• Antibiotic selection
• Decolonisation of the gut
• Paterson et al, CID 200133126-8
• Norfloxacin for 5 days

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ESBLs Infection Control

• Outbreak Management
• Special considerations for ESBLs?

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Investigation of Outbreaks

• Case control studies
• Environmental investigations
• Elucidation of the epidemiology
• RAPD typing
• Analysis of genetics
• Mechanisms of resistance
• Shannon et al, JHI 199839291-300

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Interventions

• Isolation of infected / colonised patients
• Screening of contacts for carriage
• Reinforcement of hand hygiene
• Increased environmental cleaning
• Screening of environment
• Removal of risk factors
• CVC lines
• Antibiotic restriction
• Ward closure

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Pena et al, AAC, 19984253-58
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Risk Factors

• Length of hospital stay
• Stay on ICU / mechanical ventilation
• Placement of CVC or urinary catheters
• Prior hospital stay
• Multiple courses of antibiotics
• Extended spectrum cephalosporins

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Other risk factors

• Ointment, stethoscopes, staff hands.
• Gastmeier et al, AJIC,200331424-430
• Cockroaches!
• Cotton et al, JHI, 20004413-17
• Contaminated electronic thermometers, reuse of
  single use O2 saturation probes
• Macrae et al, JHI,200149183-192
• Ultrasonography probes / gel
• Gaillot et al, JCM,1998361357-1360

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ESBLs Infection Control

• Surveillance for ESBLs?

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Antimicrobial Resistance among Pathogens Causing
Hospital-Onset Infections
3rd generation cephalosporin- resistant
Klebsiella pneumoniae
Fluoroquinolone-resistant Pseudomonas aeruginosa
Non-Intensive Care Unit Patients Intensive Care
Unit Patients
Source National Nosocomial Infections
Surveillance (NNIS) System

• Link to NNIS Online at CDC

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Susceptibility Testing Proficiency 48 Clinical
Microbiology Laboratories

• Test Organism
  Accuracy
• Methicillin-resistant S. aureus 100
• Vancomycin-resistant E. faecium 100
• Fluoroquinolone-resistant P. aueruginosa 100
• Erythromycin-resistant S. pneumoniae 97
• Carbapenem-resistant S. marcescens 75
• Extended spectrum b-lactamase K. pneumoniae
  42

Source Steward CD, et al Diagn Microbiol Infect
Dis. 20003859-67
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• To allow surveillance to really work to reduce
  ESBL infections
• Local
• Relevant
• Timely
• Robust
• Involve the infection control teams
• Involve clinicians

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ESBLs Infection Control

• Conclusions

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ESBLs Infection Control

• ESBL specific Infection Control Policies?

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• No
• Improvement in standard infection control
  procedures for all multi-resistant organisms.
• Appreciation of epidemiology and mode of spread
  to apply generic policy.

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ESBLs Infection Control

• Should we screen for ESBLs?

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• May be useful for certain units depending on the
  prevalence of resistance in their area /
  hospital.
• Screening for ESBLs alone without screening for
  other multi-resistant Gram-negatives is probably
  not helpful other than in outbreak management.

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ESBLs Infection Control

• Outbreak Management
• Special considerations for ESBLs?

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• Standard outbreak management is appropriate
• Molecular epidemiology particularly helpful
• Environmental screening particularly in areas
  that would be expected to harbour Gram negative
  organisms

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ESBLs Infection Control

• Surveillance for ESBLs?

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• Locally relevant surveillance programmes for
  multi-resistant organisms / healthcare associated
  infections in general is the way forward.

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Campaign to PreventAntimicrobial Resistance

• Centers for Disease Control and Prevention
• National Center for Infectious Diseases
• Division of Healthcare Quality Promotion

Clinicians hold the solution!

• Link to Campaign to Prevent Antimicrobial
  Resistance Online
• Link to Federal Action Plan to Combat
  Antimicrobial Resistance

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12 Steps to Prevent Antimicrobial Resistance
Hospitalized Adults