MANAGEMENT OF

MULTIRESISTANT
NOSOCOMIAL INFECTION

Infectious Diseases Unit

Internal Medicine Department
Hasan Sadikin General Hospital / Faculty of Medicine
Padjadjaran University

DEFINISI
Infeksi nosokomial
Bakteri multiresisten
PROBLEM

Lokal
Nasional
global

Klinisi
Farmasi
Pengelola

POINTS
Faktor Resiko
Pencegahan
Terapi

Terjadinya
Kolonisasi
Infeksi

Penyebaran

 CCU Ecosystem of microorganism

HCW

INANIMATE
ENVIRONMENT

PATIENTS

Critically ILL patients Endogenous flora

- Chromosom
- plasmid
Less pathogen

Resistant pathogen
fungi

Selective pressure
Of Antibiotic

Faktor Resiko

Manardi 1998
Cunha 1998,2002

Inappropriate antibiotic therapy

Prolong antibiotic therapy
Wrong combination antibiotic therapy
Infeksi sulit / multipel
Terapi kolonisasi
Standar / peraturan / policy ( - )

Pencegahan timbulnya
kuman multi resisten
Batasi antibiotik yang potensial terjadi
resistensi
Usahakan antibiotik yang kurang potensial
terjadinya resistensi
Rotaring formulary (cycling) ?
Monoterapi > kombinasi
Pengenalan antibiotik failure
Indikasi tepat untuk antibiotik tertentu

Spreading of Resistant pathogen

Invasive diagnostic
Invasive therapeutic
Devices,clothe, linen
HCW
Frequency
intencity

Risk of noso. inf

Pencegahan penyebaran kuman

multi resisten
Surveilance
Universal precaution, droplet precaution,
contac precaution, air borne precaution
Empiric precaution
Isolation (BSI, single room, cohort)
Peraturan antara lain transportasi
Hand washing

DIAGNOSTIK MDR
Reliable laboratorium
Regular report
Early detection

Antibiotic policies / noso. control program

National & local
Guidelines

Control the emergence of resistant

strains
Education, out break investigation, surveilance
Committee/ :- clinician
team
- microbiologist
- pharmacist
- administration, epidemiologist
- nurse
Antibiotic resistance pattern report & routine feedback.
Restriction : (indication)
- high potential to resistance
- broad spectrum

KAKKILAYA (2005)
We must exercise considerable restraint in
prescribing antibacterials. Restrict a.b use
to only certain definite indications
Definitive
therapy
Cost-effective :

Empirical
therapy

Prophylactic
therapy

Narrower spectrum; SE
Cheaper; easy adm; resistency

50 % A. B. use in CCU : unjustification/ documented (-)

Review report : Antibiotic pattern
Reliable culture results clinical entity
Modification / reassesment
Change
Superinfection
Non infection
Drug fever

Combination
Monoterapi is preffered
Certain indication
- anti TBC
- anti pseudomonas
- mix infection spectrum
Combination
resistant m.o
?

Rotation (cycling)
Controversi
Resistance to both agents
still emerge
Alternative to restriction

Vancomycin use (avoid VRE)

acceptable

Discouraged

1. Betalactame
resistance m.o
2. Gram + infection but
betalactam allergy
3. Antibiotic
associated colitis +
fails to metronidazol

1. MSSA
2. Skin contamination with
Staphyloccocus is likely
3. Continued empiric use,
while culture ( - ) for
betalactam resistant gram
positive
4. MRSA colony eradication
5. Topical use

Hand washing / Antiseptic

Simple, education!
Studies : - Sampling of physician hand : gram (-) rod, S. aureus
- Routine washing skin bact. Carriege noso.
Infection
before and after contact (patient/procedure/source/gloves)
Antiseptic soap/solution : e.g chlorhexidine
water/plain soap Heavy contamination?
Gloves Physical barrier

Surveillance
Most important of inf. Control program
Baseline Rate; infection rate
recognition of potential outbreaks
early identification : - special patients
- resistant m.o
- outbreaks
Collecting, analyzing

 Re-usable device : - disinfection

- sterilization
Physical plant/Engineering
- facilitate inf. controle
- limit infection spread
Isolation precaution (private,cohort)
Droplet precaution (e.g meningococus, MRSA)
Airborne precaution ( e.g TBC)
Contact precaution ( e.g MRSA, VRE)

MDR Noso. Infection

Easy to be transmitted :
VRE
MRSA
Others :
- ESBL-gram negative (e.g pseudomonas)
- MDR TB
- GISA

Pengobatan MDR Pathogin

Sulit
Jenis kuman? Pola resistensi?
MRSA
Mudah menyebar
VRE

MRSA (Methicillin-resistant Staph. Aureus) (1)

Resistant to : betalactam, and usually

(occassionally) other antibiotics
Special lab test
Readily & easily transmitted
Difficult & expensive to control and to treat

MRSA

(2)

Good colonizers
Transmission : hand of HCW, equipment, clothing,
air.
Screening : admission, staff
Notify it transferred
Isolation for patients and treat (single or cohort
room?)
Treatment infected patients :
- Vancomycin
- Vancomycin + gentamycin /
rimfampycin / cotrimmoxazole

MRSA (3)

Sampling sites : 2/3 negative results

(patients, room)
clearance
MRSA control
- Surveillance early detection
- Isolation & treat
Nasal (local) 1 week

Mupirocin topical 2%
chlorhexidine 1%
neomycin
bacitracin

MRSA

(4)

Bathing (shower) 1 week

Chlorhexidine 2%
triclosan

Prophylactic : during outbreaks

Droplet precaution
Hand washing + disinfection
Gloves, apron, gown when handling
patients
Disinfecting before opening

VRE = glycopeptide resistant

Enteroccocus
Resistance to vanco and other agents
(aminoglycoside, ampicillin)

Difficult to treat
Risk factors :
- broad spectrum A.
- vancomycin
- prolonged hospitalization
- others
Measures to limit the spread
eg.:
- strict limitation of vancomycin
- precautions
Treatment : - linezolid; quinepristin/dalfopristin
- UTI : Nitrofurantoin, Fluoroquinolon

Strep. Pneumoniae
Resistance to : Penicillin

cephalosporin

a.l macrolide, tetra, chloramph.

Pattern ~ lokalisasi
Th/: - mic < 2 mg/L to penicillin dosis / cefotaxime,
ceftriaxone
- high level of resistance: imipenem,glycopeptides
- pnemococcal menginitis : ceftriaxone + vanco.

Pseudomonas Aeruginosa
The most adaptable m.o
Resistance to ceftazidine
to : amikacin
cipofloxacin
imipenem
PROBLEM

 Kasus : multiresistant klebsiella

, 70 th, stroke
urine culture : K. pneumoni yang
resistensi semua A.B kecuali imipenem
Marin Kollef (2003) : Gr-(e.g Kleb.Pn; E.
Coli often produce ESBLs
Reese (1996) multidrug resistant
outbreak of klebsiella spp have been
reported.They are still susceptible to
imipenem.

 LEVLY :
To deal with MDR m.o
all of us: physician, patient, microbiologist
pharmacist, P.H/epidemiologist, infection
control practitioner.
Some MDR pathogen untreatable
Closely monitor individual (local) antibiogram
Preventing MDR - m.o most logical approach
Surveillance : a.b m.o - infection

KESIMPULAN
1. Waspadai terjadinya dan penyebaran
kuman multiresisten di rumah sakit
2. Kenali faktor resiko
3. Pencegahan terjadinya kuman tsb.
4. Deteksi dini
- cegah penyebaran
- pengobatan