HEALTH CARE

ASSOCIATED INFECTIONS
CREATING DRUG RESISTANCE
ATLAS
(INCORPORATING CDC GUIDELINES)

Dr.T.V.Rao MD

3/22/16

Dr.T.V.Rao MD

Healthcare-associated infections
Healthcare-

associated
infections (HAIs)
are a major, yet
often preventable,
threat to patient
safety
3/22/16

Dr.T.V.Rao MD

A question to Many

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Dr.T.V.Rao MD

Hospital Breed Many Infections

How good we are to detect makes
difference?

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Dr.T.V.Rao MD

The Hospitals and Microbiology Departments

should create documentation on

central line-associated bloodstream infections

(CLABSI),

catheter-associated urinary tract infections

(CAUTI),

surgical site infections (SSI),

hospital-onset Clostridium difficile infections

(C difficile), and

hospital-onset methicillin-resistant
Staphylococcus aureus
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Dr.T.V.Rao MD

The report includes data reported to

Hospital Infection control committee from
the following
CLABSI: intensive care
units, neonatal intensive
locations:
care unit,

and

wards

CAUTI: intensive care units and wards

C difficile: all inpatient locations in the facility,

with the

exception

well-baby

of the neonatal intensive care units and

locations

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Dr.T.V.Rao MD

MRSA bacteremia: all inpatient locations in the

Microbiology Departments
should Document on
pathogens
The Antibiotic
documentation
includes resistance
data for 31 bugdrug profiles (or
phenotypes,
pathogen-antibiotic
combinations that
3/22/16

Dr.T.V.Rao MD

These phenotypes include:

Methicillin-resistant

Staphylococcus aureus
(MRSA)
Carbapenem-resistant

Enterobacteriaceae
(CRE)
Multidrug-resistant

Pseudomonas
aeruginosa
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Dr.T.V.Rao MD

HOSPITALS CAN
CREATE ANTIBIOTIC
RESISTANCE ATLAS

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Dr.T.V.Rao MD

Why we Need to Create an Atlas

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Dr.T.V.Rao MD

10

Staphylococcus aureus
S.aureus

cause a range of illnesses, from skin and

wound infections to pneumonia and bloodstream
infections that can cause sepsis and death.

Staph bacteria, including those resistant to first line

therapy, methicillin-resistant S. aureus(MRSA),

are the second most common causes of

healthcare-associated infections according to a
2011 national prevalence survey performed by CDC
(http://www.cdc.gov/HAI/surveillance/index.html).

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Dr.T.V.Rao MD
11
Less
severe infections are
common and occur outside

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Dr.T.V.Rao MD

12

Phenotype Analytical Definitions

Methicillin-Resistant Staphylococcus aureus (%R)

Analytical

Definition:
Staphylococcus
aureus that has
tested resistant
(R) to at least 1
of the following:
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Dr.T.V.Rao MD

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MRSA with Communityassociated Resistance Pattern

(%R)
Any

MRSA that has tested

resistant (R) to erythromycin
and sensitive (S) to
trimethoprimsulfamethoxazole and has at
least one of the following
additional properties:

1.

Tested Sensitive (S) to both

ciprofloxacin and levofloxacin

2.

Tested Sensitive (S) to

clindamycin

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Dr.T.V.Rao MD

14

Documents to Create Atlas

Linezolid-Resistant
MRSA

MRSA (%R)

that has tested resistant (R) to linezolid

Fluoroquinolone-Resistant

MRSA (%R)

MRSA

that has tested resistant (R) to ciprofloxacin and/or

levofloxacin

Vancomycin-Intermediate
MRSA

that has tested intermediate (I) to vancomycin

Daptomycin-Resistant
MRSA

MRSA (%I)

MRSA (Resistant or Intermediate) (%R*)

that has tested non-susceptible (NS) to daptomycin

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Dr.T.V.Rao MD

15

Acinetobacter spp
Pathogen

Overview

Acinetobacter is a type of gram-negative

bacteria that is a cause of pneumonia or
bloodstream infections among critically ill
patients.

Fewer than 1 of 10 healthcare-associated

infections are caused by Acinetobacter;
however, according to a 2011 national
prevalence survey performed by CDC, many of
these bacteria have become very resistant to
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Dr.T.V.Rao MD
16
antibiotics. Some strains are resistant to

Carbapenem-

Phenotype

Resistant
Analytical
Definitions
Acinetobacter spp.
(%R*)
Any

3/22/16

Acinetobacter
spp. that has
tested either
intermediate (I) or
resistant (R) to at
least one of the
following:
imipenem,

Dr.T.V.Rao MD

17

MDR Acinetobacter spp. (%R)

Any

Acinetobacter spp. that has tested either intermediate (I) or

resistant(R) to at least one drug in at least 3 of the following
6categories:

1.

Extended-spectrum cephalosporins (cefepime, ceftazidime,

cefotaxime, ceftriaxone)

2.

Fluoroquinolones (ciprofloxacin, levofloxacin)

3.

Aminoglycosides (amikacin, gentamicin, tobramycin)

4.

Carbapenems (imipenem, Meropenem, doripenem)

5.

Piperacillin Group (piperacillin, piperacillin/tazobactam)

6.

Ampicillin/sulbactam
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Dr.T.V.Rao MD

18

E.coli

Pathogen

Overview

E.coli cause pneumonia, urinary tract infections,

and bloodstream infections in hospitalized
patients.

E. coli bacteria are the fourth most common

cause of healthcare-associated infections
according to a 2011 national prevalence survey
performed by CDC.

Carbapenem-Resistant E.coli is a subset of the

nightmare bacteria carbapenem-resistance
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Dr.T.V.Rao MD
Enterobacteriaceae
(CRE).

19

Phenotype Analytical
Definitions
Carbapenem-Resistant

E.coli (%R)

Any

E.coli that has tested resistant (R) to at least one of the

following: imipenem, meropenem, doripenem, ertapenem

Extended-Spectrum

Cephalosporin-Resistant E.coli (%R)

Any

E.coli that has tested resistant (R) to at least one of the

following: ceftriaxone, ceftazidime, cefepime, and cefotaxime

Fluoroquinolone-Resistant

E.coli (%R)

Any

E.coli that has tested resistant (R) to at least one of the

following: ciprofloxacin, levofloxacin, and moxifloxacin
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Any

MDR E.coli (%R)

E.coli that has tested either intermediate

(I) or resistant (R) to at least one drug in at
least 3 of the following 5 categories:

1.

Extended-spectrum cephalosporins
(cefepime, cefotaxime, ceftazidime,
ceftriaxone)

2.

Fluoroquinolones (ciprofloxacin, levofloxacin,

moxifloxacin)

3.

Aminoglycosides (amikacin, gentamicin,

tobramycin)
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Enterobacter spp.
Pathogen

Overview

Enterobacter spp. bacteria cause pneumonia, urinary tract

infections, and bloodstream infections in hospitalized
patients.

Fewer than 1 of 10 healthcare-associated infections are

caused by Enterobacter spp; however, according to a 2011
national

prevalence

survey performed by CDC, many of these bacteria

have become very resistant to antibiotics. Some strains
areresistant to nearly all or all antibiotics.

Carbapenem-Resistant Enterobacter is a subset of the

3/22/16
Dr.T.V.Rao MD
nightmare
bacteria carbapenem-resistance
Enterobacteriaceae (CRE).

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Phenotype Analytical
Definitions
Carbapenem-Resistant

(%R)

Enterobacter spp.

Any

Enterobacter spp. that has tested

resistant (R) to at least 1 of the following:
imipenem, meropenem, doripenem,
ertapenem

Extended-Spectrum

CephalosporinResistant Enterobacter spp. (%R)

3/22/16
Any
Enterobacter

spp. that has tested

Dr.T.V.Rao MD

23

MDR Enterobacter spp. (%R)

Any

Enterobacter spp. that has tested either intermediate (I)

or resistant (R) to at least one drug in at least 3 of the
following 5categories:

1.

Extended-spectrum cephalosporins (cefepime, cefotaxime,

ceftazidime, ceftriaxone)

2.

Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin)

3.

Aminoglycosides (amikacin, gentamicin, tobramycin)

4.

Carbapenems (imipenem, meropenem, doripenem,

ertapenem)

5.

Piperacillin Group (piperacillin, piperacillin/tazobactam)

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Dr.T.V.Rao MD

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Klebsiella spp.
Pathogen

Overview

Klebsiella spp. bacteria cause pneumonia, urinary

tract infections, and bloodstream infections in
hospitalized patients, as well as patients in nursing
homes and other healthcare facilities.

Klebsiella spp. bacteria are the third most

common cause of healthcare-associated infections
according to a 2011 national prevalence survey
performed by CDC. Klebsiella spp. are becoming
more resistant to even antibiotics of last resort,
3/22/16
Dr.T.V.Rao MD
such as carbapenems.

25

 Any

Phenotype Analytical Definitions

Carbapenem-Resistant Klebsiella
spp. (%R)

Klebsiella oxytoca or Klebsiella

pneumoniae that has tested
resistant (R) to at least 1 of the
following: imipenem,
meropenem,doripenem, ertapenem

Extended-Spectrum

CephalosporinResistant Klebsiella spp. (%R)

Any

Klebsiella oxytoca or Klebsiella

pneumoniae that has tested
resistant (R) to at least one of the
following: ceftriaxone, ceftazidime,
cefepime, cefotaxime
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Dr.T.V.Rao MD

26

MDR Klebsiella spp. (%R)

Any

Klebsiella oxytoca or Klebsiella pneumoniae that has

tested either intermediate (I) or resistant (R) to at least one
drug in at least 3 ofthe following 5 categories:

1.

Extended-spectrum cephalosporins (cefepime, cefotaxime,

ceftazidime, ceftriaxone)

2.

Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin)

3.

Aminoglycosides (amikacin, gentamicin, tobramycin)

4.

Carbapenems (imipenem, meropenem, doripenem,

ertapenem)

5.

Piperacillin Group (piperacillin, piperacillin/tazobactam)

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Dr.T.V.Rao MD

27

Pseudomonas aeruginosa
Pathogen

Overview

Pseudomonas aeruginosa is a common cause of healthcareassociated infections including pneumonia, bloodstream

infections,urinary tract infections, and surgical site infections.

Pseudomonas

aeruginosa bacteria are the third most common

cause of healthcare-associated infections according to a
2011national prevalence survey performed by CDC. P.
aeruginosa are becoming more resistant to even antibiotics of
last resort, such as carbapenems.

Find more information about multidrug-resistant

Pseudomonas aeruginosa in the AR Threat Report
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Dr.T.V.Rao MD

28

Phenotype Analytical
Definitions

Carbapenem-Resistant

Pseudomonas aeruginosa
(Resistant or Intermediate) (%R*)

Any

Pseudomonas aeruginosa that has tested

either intermediate (I) or resistant (R) to at least
1 of the following: imipenem,meropenem, or
doripenem

Extended-Spectrum

Cephalosporin-Resistant
Pseudomonas aeruginosa (%R)

Any

Pseudomonas aeruginosa that has tested

resistant
(R) to at least one
3/22/16
Dr.T.V.Raoof
MD the following:
cefepime and ceftazidime

29

 Any

MDR Pseudomonas
aeruginosa (%R)

Pseudomonas aeruginosa that has tested

either intermediate (I) or resistant (R) to at least 1
drug in at least 3 of the following 5categories:

1.

Extended-spectrum cephalosporins (cefepime,

ceftazidime)

2.

Fluoroquinolones (ciprofloxacin, levofloxacin)

3.

Aminoglycosides (amikacin, gentamicin,

tobramycin)

4.

Carbapenems (imipenem, meropenem,

3/22/16
Dr.T.V.Rao MD
doripenem)

30

Other resistant patterns of

Pseudomonas
Fluoroquinolone-Resistant

Pseudomonas aeruginosa (%R)

Any

Pseudomonas aeruginosa that has tested resistant (R) to at

least one of the following: ciprofloxacin, levofloxacin

Aminoglycoside-Resistant

Pseudomonas aeruginosa (%R)

Any

Pseudomonas aeruginosa that has tested resistant (R) to at

least one of the following: amikacin, gentamicin, tobramycin

Pip/Tazobactum-Resistant

Pseudomonas aeruginosa (%R)

Any

Pseudomonas aeruginosa that has tested resistant (R) to at

least one of the following: piperacillin, piperacillin/tazobactam
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Dr.T.V.Rao MD

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Enterococcus faecium

Pathogen Overview

Enterococci cause a range of illnesses, mostly among patients receiving

healthcare, but include bloodstream infections, surgical site infections, and
urinary tract infections.

Overall, Enterococcus spp. are the fifth most common cause of healthcareassociated infections according to a 2011 national prevalence survey performed
by CDC.

The proportion of infections that occur with a vancomycin-resistant strain

differs by the two most common species of

Enterococcus.

Find more information on Vancomycin-resistant Enterococcus faecium in the

AR Threat Report.
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Dr.T.V.Rao MD

32

Phenotype Analytical Definitions

Vancomycin-Resistant

Enterococcus faecium (%R)

Any

Enterococcus faecium
that has tested resistant
(R) to vancomycin

Daptomycin-Resistant

Enterococcus faecium
(%R*)
Any

Enterococcus
faecium
3/22/16
that has tested non-

Dr.T.V.Rao MD

33

Enterococcus faecalis

Pathogen Overview

Enterococci cause a range of illnesses, mostly among patients

receiving healthcare, but include bloodstream infections, surgicalsite
infections, and urinary tract infections.

The proportion of infections that occur with a vancomycin resistant

strain differs by the two most common species ofEnterococcus.

Overall, Enterococcus spp. are the fifth most common cause of

healthcare-associated infections according to a 2011
nationalprevalence survey performed by CDC.

Find more information on Vancomycin-resistant Enterococcus

faecalisin the AR Threat Report
3/22/16

Dr.T.V.Rao MD

34

Phenotype Analytical
Definitions
Vancomycin-Resistant

Enterococcus faecalis (%R)

Enterococcus

faecalis that
has tested resistant (R) to
vancomycin

Daptomycin-Resistant

Enterococcus faecalis (%R*)

Enterococcus

faecalis that
has tested non-susceptible
(NS) to daptomycin

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Dr.T.V.Rao MD

35

Coagulase-Negative
Staphylococci
Pathogen

Overview

Coagulase-negative

staphylococci
infections cause bloodstream
infections and infections of
prosthetic material. Overall, these
bacteria, commonly found on the
skin, are associated with only
about 1 out of every 10 healthcareassociated infections according to
a 2011 national prevalence survey
performed by CDC.
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Dr.T.V.Rao MD

36

Understanding Coagulase
Negative Staphylococcus

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Dr.T.V.Rao MD

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Phenotype Analytical
Vancomycin-Resistant
Coagulase-Negative
Definitions
Staphylococci (Resistant or

Intermediate) (%R*)

Coagulase-Negative

Staphylococci that has

tested resistant(R) or
intermediate(I) to
vancomycin
Vancomycin-Resistant

Coagulase-Negative
Staphylococci (%R)
Coagulase-Negative
3/22/16

Staphylococci that has

tested resistant(R) to

Dr.T.V.Rao MD

38

Enterobacteriaceae spp.
Pathogen

Overview

The three most common types of

Enterobacteriaceae causing healthcare acquired
infections include Enterobacter spp.,Klebsiella
spp., and E.coli.

These bacteria cause pneumonia, urinary tract

infections, and bloodstream infections in patients.

Emerging resistance to carbapenems makes

treating these resistant infections very difficult.

Find more information on carbapenem-resistant

3/22/16
Enterobacteriaceae
in theDr.T.V.Rao
AR MD
Threat Report.

39

Phenotype Analytical
Definitions
Any

E.coli,
Klebsiella oxytoca,
Klebsiella
pneumoniae, or
any Enterobacter
spp. that has
tested resistant
(R) to at least one
of the following:

3/22/16

Dr.T.V.Rao MD

40

3/22/16

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41

In spite of Many Developments Hand

Washing still continues to be great
boon to stop spread of Hospital
Associated Infections

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Dr.T.V.Rao MD

42

Hand Washing Saves Many

Lives
Are we Practising

3/22/16

Dr.T.V.Rao MD

43

FOR MORE INFORMATION ABOUT THE

AR ATLAS, VISIT:
HTTP://WWW.CDC.GOV/HAI/SURVEILL
ANCE

3/22/16

Dr.T.V.Rao MD

44

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Clinical and Diagnostic Microbiology with more emphasis on Infectious diseases and Hospital
associated Infection wish to be your partner in educating many millions who know well the
importance of Infectious diseases

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can visit many web sites of mine

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Program

Created by Dr.T.V.Rao MD for

Benefit of Medical and Paramedical
Professionals in the Developing World
Created from World Wide Resources
Email
doctortvrao@gmail.com
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Dr.T.V.Rao MD

46