Tag Archives: MDRO

“The Blind Microbiologist”

blindI have authorised a little flurry of urine cultures recently with ESBL producing organisms. A good proportion of these had no clinical details, and a significant proportion were from Rest Home residents.

It is the lack of clinical information which frustrates me the most..

These urine samples could have been taken for any one of the following reasons:

  • a)  The nurse at the Rest Home had decided to routinely dipstick the urine of all the residents.
  • b)  The urine was taken and sent to the lab because there was a “whiff” of urine from the patient.
  • c)  The patient is known to be MDRO colonised, so another urine was taken to ‘check’ if it is still there.
  • d)  The patient gets a 6 monthly urine sample sent to the lab because they are known to have a history of recurrent UTIs.
  • e)  The patient is new to the practice or Rest Home so an initial screening urine was taken off.
  • f)  The patient had symptoms or signs suggestive of an acute urine infection.

It is dangerous to assume that the majority of urines arriving at your lab (without clinical details) are specifically for reason F.

My bet is that this is not the case…

When we release antibiotic susceptibilities from the laboratory on a urine culture, we are essentially giving the green light for antibiotic use. An ‘endorsement’ of sorts, a licence to treat, regardless of the clinical indication. In essence we are reporting susceptibilities “blind”…

However reason F is the only reason listed above where I would actually want to routinely release susceptibilities. It could easily be argued that for the laboratory to release susceptibilities on an MDRO without there being any clinical details, simply represents poor antibiotic stewardship.

My laboratory has recently made the provision of clinical details mandatory for Infectious serology tests. If no clinical details, then the serum is simply stored until they are provided. Uptake by clinicians has been very good, and there have been virtually no complaints. What is there to complain about? The quality gains that we have made from this have been very significant.

I am now wondering whether a similar model should be applied to urine samples. Obviously specimen integrity (and ease of recollection) should be taken into account, but there are a couple of possible models as follows:

  • No clinical details, urine stored for maximum 24 hrs until provided. Otherwise recollect.
  • No clinical details, urine processed, but susceptibilities only released on provision of clinical details.

As microbiologists, I don’t think we should be scared of having these kinds of conversations. In fact, I believe we owe it to our patients…

Michael

p.s. Book sales going well, approximately 50 copies ordered so far. They are being posted within 24 hours of receipt of order but obviously will take a few days to arrive depending on location. Let me know if any problems in the ordering process. Thanks.

“Pressure Control”

Controlling the volume of Multi-Drug Resistant Organisms (MDROs) within an institution is just as much about controlling the selection pressure as it is about controlling the transmission. (Don’t tell the Infection Control nurses that, but it is absolutely true!)

In my opinion the selection pressure control is actually the more important of the two. There will always be transmission despite our best efforts…

For those who are involved with antimicrobial stewardship and Infection Control, you will be aware that we are very good at monitoring our MRSA/ESBL/VRE/CRE rates etc., etc. We look at pretty graphs illustrating this every month at our committee meetings.

However we are not so good at monitoring our selection pressure. By this I mean that we should be taking 5 or 6 key broad spectrum antibiotics (e.g. meropenem, piperacillin tazobactam, tigecycline, ciprofloxacin, etc.) and monitoring objectively their usage on a month by month or quarter by quarter basis.

Most of us have guidelines on the clinical indications for the appropriate use of these key broad spectrum antibiotics. Some institutions go further and require endorsement by an Infection Specialist before their use. However very few of us actually monitor this usage in an objective fashion and then present these surveillance findings at monthly infection control/stewardship meetings.

I have come across institutions with sophisticated antimicrobial stewardship guidelines and well established anti-microbial stewardship committees. Yet the same institutions can have ITUs where more than half the patients passing through the door will get a carbapenem. An MDRO arriving in such a unit simply thinks all his birthdays have come at once, and will make himself at home in no time at all…

That is selection pressure!

If I was a CEO of a hospital that had a problem with endemic Carbapenem Resistant Enterobacteraciae (CRE), I would want to know exactly how much of each of the key broad spectrum antibiotics were being used in the hospital, and then whereabouts they were being used, by whom, and why.

For me, the antimicrobial pharmacist is one of the key members of any infection control team. You can write as many guidelines as you want, but unless you have a firm handle on exactly how much selection pressure you have in your hospital, and how that pressure is trending over time, you may find yourself sitting on an MDRO time bomb.

Michael

Do bacteria have birthdays? Not sure about that!

MDRO Screening: Part 1: “Made to Measure”

I am talking here about Multi-Drug Resistant Organisms in the bacterial sense, ie MRSA, ESBLs, VRE etc.

The first thing to say is that in New Zealand we don’t see that many of them, certainly compared with other countries in the world. Click here for more about this.

But what I want to focus on here is the measurement of MDRO rates. There are two main ways to measure these rates.

  • 1) Crude Rates: The total number of MDRO isolates per population. e.g number of MRSA isolates per 100,000 population. This is the type of measurement preferred by reference laboratories as they often only receive the resistant isolates, not the susceptible ones…. However this type of rate varies widely depending on how much screening is done at any one institution. The more MDROs are looked for, the more that will be found. The amount of MDRO screening performed in New Zealand varies dramatically from one hospital to another dependent on contractual and other factors.
  • 2) As a percentage of total isolates. The MDRO rate can also be measured as a percentage of the total number of bacterial isolates, both susceptible and resistant. e.g The MRSA percentage rate is calculated by calculating the number of MRSA isolates as a percentage of the total Staphylococcus aureus isolates (both methicillin susceptible and resistant). A further example is the percentage of ESBL producing E.coli as a percentage of total E.coli.

I prefer the latter method. I think it is more comparable across areas and it also allows better comparison of rates over time. The Crude MDRO rate measurement is too biased by the amount of testing done and is also susceptible to population fluctuation.

I am not saying that the percentage method is perfect. Like all these things it is susceptible to bias also…..

Currently in our laboratories (NZ): (2012)

  • 10% of our total Staph aureus isolates are methicillin resistant (MRSA)
  • 1% of our E.coli isolates are ESBL producing.
  • 11% of our K. pneumoniae isolates are ESBL producing.

When I return to work in Europe it will interesting to compare the percentage rates with what I am currently used to and speculate as to the differences.

Michael