MedSurg Ch 21 Caring for Multidrug-Resistant Organism Infectious Disorders

The best way to prevent the spread of MRSA or anything else is

Handwashing

Contact transmission

Direct- Person-to-person transfer of microorganisms (touching, kissing)

Indirect- Transfer via an inanimate object (fomite) or contaminated surface

Inanimate objects capable of carrying and transferring infectious organisms

Airborne Transmission

Pathogens are carried in the air in droplets or dust particles and inhaled by a host (TB, measles, COVID-19)

Vehicle Transmission

Indirect transmission via a non-living contaminated source, such as food, water, or blood

Vector transmission

Transmission by a living organism (vector) such as mosquitoes, ticks, or fleas, which bite or infect a human host

What is a nosocomial infection?

An infection acquired in the hospital that was not present or incubating on admission

Catheters (urinary or vascular), surgical sites, ventilators, contaminated hands or surfaces

Methicillin-Resistant Staphylococcus aureus

a leading cause of healthcare-associated infections (HAIs) and is associated with high morbidity and mortality, increased length of stay, significant cost burden

Risk Factors for HA-MRSA

Hospitalization within past 18 months

Admission with skin or soft tissue infection

ICU admission

LTC facility residence

Invasive procedures (IVs, catheters, surgery)

Hemodialysis

Broad-spectrum antibiotic use

Immunocompromised state

Comorbidities: HIV/AIDS, diabetes, CHF, COPD, cancer

Risk Factors for CA-MRSA (community aquired)

Age < 2 years, athletes (especially contact sports), IV drug use, men who have sex with men, military recruits, incarcerated individuals, residents of shelters

Crowded living conditions, sharing personal items (razors, needles, towels), close skin-to-skin contact, poor hygiene

Which are risk factors for MRSA infection? (Select all that apply.)

A.  Surgery

B.  Urinary catheters

C.  Antibiotic use

D.  Feeding tubes

E.  Recent hospitalization

Surgery

Urinary catheters

Abx use

Recent hospitalization

MRSA s/s

Pneumonia

Skin and soft tissue infection

Bloodstream infection

May look like a spider bite

MRSA complications

Increased morbidity and mortality
Osteomyelitis
Toxic shock syndrome
Multisystem organ failure

The nurse is screening patients for their risk of developing VRE. The nurse should consider which patient at greatest risk?

A.  The patient cared for at home

B.  The patient with prolonged antibiotic exposure

C.  The patient in a small community hospital setting

D.  The patient hospitalized for an uncomplicated procedure

The patient with prolonged antibiotic exposure

Vancomycin-Resistant Enterococci (VRE)

a type of bacterial infection where the bacteria are resistant to the antibiotic vancomycin

usually found in Urinary tract (UTI), Intra-abdominal and pelvic wounds (peritonitis), bloodstream (bacteremia/sepsis)

MRSA can

cause osteomyelitis

VRE risk factors

Prolonged hospitalization

Immunosuppression (transplant, cancer, ICU)

Prolonged/Recent vancomycin or cephalosporin use

Urinary tract infections (UTIs)

Invasive devices (catheters, central lines)

Severe comorbidities (hematologic malignancies)

Clinical Manifestations of VRE

UTI, intra-abdominal and pelvic wounds (peritonitis), bloodstream (bacteremia/sepsis), wounds (will present with redness, heat, drainage)

-Fever

-Tachycardia

-Hypotension

VRE complications

Prolonged hospital stays and antimicrobial therapy, increased costs, higher mortality from bacteremia, osteomyelitis, pneumonia, sepsis, infective endocarditis (3rd most common cause)

Clostridioides difficile (C. diff)

a bacterium that can cause diarrhea and colitis (inflammation of the colon)

Cdiff risk factors

Antimicrobial use, age > 64, chemotherapy, GI surgery, NG or feeding tubes, acid-suppressing meds (H2 blockers, PPIs), immunosuppression, prolonged hospitalization, impaired bowel motility

C.Diff patho

Fecal-oral route

Healthcare worker hands

Environmental contamination

-Is resistant to disinfectants, heat, dryness, can survive for months on surfaces

What is the hallmark clinical symptom of C. diff infection?

Loose, watery stools (≥3 in 24 hrs), sometimes with mucus or occult blood, abdominal pain and cramping, positive stool sample, fever > 101.3

What are the complications of C. diff infection?

Volume depletion & hypotension, renal insufficiency, electrolyte imbalances, hypoalbuminemia, peritonitis, paralytic ileus, toxic megacolon, fulminant pseudomembranous colitis, sepsis, death

C.diff surgical interventions

Subtotal colectomy

Total colectomy for - fulminant colitis, toxic megacolon, paralytic ileus, refractory sepsis

Endocarditis treatment

no FDA approved treatments currently

What type of hand hygiene is needed to prvent c.diff spread

Wash hands don’t use hand sanitizer

Multidrug-Resistant Acinetobacter baumannii is resistant to

Carbapenems

Fluoroquinolones

Ampicillin/sulbactam

Trimethoprim/sulfamethoxazole (Bactrim)

Multidrug-Resistant Acinetobacter baumannii risk factors

Recent surgery, central venous catheters, tracheostomy, mechanical ventilation, enteral feedings, bed-ridden status, fluoroquinolone or carbapenem use, prior MRSA colonization, hemodialysis, malignancy, glucocorticoid therapy, prior hospitalization or ICU stay, residence in a long-term care facility

Acinetobacter baumannii patho

Naturally inhabits water, soil, animals, and
humans; contact transmission
-Recovered from human skin, throat, and rectum
-May colonize respiratory tract
Can survive for weeks to months on surfaces

What are the most frequent clinical manifestations of A. baumannii infections?

Ventilator-associated pneumonia (VAP)

Bloodstream infections (bacteremia/sepsis)

What complications are associated with MDR A. baumannii infections?

↑ Mortality and morbidity

Prolonged hospitalization and ICU stay

Longer ventilator days

Higher healthcare costs

Carbapenem-Resistant Enterobacteriaceae (CRE) is

resistant to nearly all available antibiotics; 50% mortality for bloodstream infections

may cause meningitis

Carbapenem-Resistant Enterobacteriaceae (CRE) risk factors

Hospitalized or long-term care patients

Older adults

Patients with indwelling devices- urinary catheters, IV lines, feeding tubes

Patients on mechanical ventilation

Patients receiving long-term or broad-spectrum antibiotics

diabetes, heart disease, renal disease

Carbapenem-Resistant Enterobacteriaceae (CRE) patho

Infected or colonized individuals

Contaminated skin, stool, wounds

Surfaces and equipment in healthcare settings

What are the common signs and symptoms of CRE infection?

Fever

Chills

Signs of sepsis (hypotension, tachycardia, altered mental status)

What is the gold standard for diagnosing MDRO infections?

bacterial culture

Medical management of Multidrug-Resistant
Organisms

wash hands with soap and water to prevent spread, patients should be placed on contact precautions

Isolation requirements for patients with MDROs

-Use isolation precautions
-Perform hand hygiene before donning PPE
-Secure gowns at neck and waist
-Remove gown and gloves before room exit
-Perform hand hygiene again upon exit

What is the first-line IV/oral antibiotic for MRSA?

Vancomycin (Vancocin)

other abx include - Linezolid (Zyvox), Daptomycin, Clindamycin (Cleocin), Bactrim

The two major treatments recommended for VRE

are linezolid and daptomycin

What is the first-line abx treatment for initial severe C. diff?

oral Vanc

When is IV Metronidazole used in C. diff?

When oral vancomycin is not effective due to ileus or toxic megacolon

The nurse is reviewing orders for a newly admitted patient with C. diff. The nurse will follow up with the provider about which order?

A.  PO Flagyl

B.  Probiotics

C.  Encouraging fluid intake

D.  Imodium

Imodium

It is imperative that tobramycin peak levels

are drawn on time (30 minutes after IV administration and 1 hour after IM administration) and trough levels should be obtained every 3 to 4 days to maintain a therapeutic dose

obramycin maintains the highest susceptibility rates for

Acinetobacter

The nurse is screening patients for their risk of developing Acinetobacter infections. The nurse should consider which patient(s) at greatest risk? (Select all that apply.)

A.  The patient on mechanical ventilation

B.  The patient with a high-acuity illness

C.  The patient recovering in the ICU overnight after surgery

D.  The patient with prolonged antibiotic exposure

E.  The patient with a wound infection

The patient on mechanical ventilation
The patient with a high-acuity illness
The patient with prolonged antibiotic exposure

What is the priority intervention to prevent the spread of MDROs?

A.  Hand washing

B.  Diagnostic cultures

C.  Isolation precautions

D.  Antibiotic administration

Hand washing

Assessment for MDROs

Fever, tachycardia, tachypnea (infection/increased metabolic demand), low BP (sepsis, hypovolemia from C. diff)

Decreased O2 sat (pneumonia)

Pain levels

Skin turgor, mucous membranes (hydration), urine output (renal perfusion), bowel movements and skin integrity

Wound site (infection signs)

Labs- ↑ WBCs, ↑ creatinine, altered electrolytes, ↓ albumin

Nursing interventions for MDRO

Hand hygiene

Place patient on isolation precautions

Administer abx as ordered, administer fever reducer, administer pain medications, administer IV fluids as ordered

Administer supplemental oxygen, administer chest physiotherapy

Encourage early mobilization

Stop administration of causative agent, wound care, cleanse perineum and add barrier cream, may use FMS, encourage family visits and telephone/TV usage to prevent depression

Nursing teaching for MRDO

Contact-isolation precautions
Take medications as prescribed
Clinical manifestations of infection
Sun protection

Last resort abx for CRE

Carbapenems - colistin, tigecycline, and fosfomycin