Multidrug resistant organisms – an update for residential care
The increase in bacteria that are resistant to antibiotics is now a major concern for healthcare providers across the world. Recently the UK’s top doctor, Dame Sally Davies, described antibiotic resistance as ‘serious a threat as terrorism’, predicting that people may die from routine post operative infections within 20 years as there would be no effective antibiotics available.
Multidrug resistant organisms (MDRO or MRO) are organisms that are resistant to several antibiotics to which they would normally be susceptible or two or more classes of antibiotics1. This means that the choice of antibiotics to treat an infection with an MDRO is usually not the first one and may have limited effect.
The MDRO that are most commonly encountered in residential care are MRSA (methicillin resistant Staphylococcus aureus) and extended-spectrum β-lactamase (ESBL) producing organisms. However there are some new kids on the block, which, although seen more in the acute healthcare sector, are finding their way into our residential care facilities. These very resistant superbugs include Vancomycin resistant enterococci (VRE) and Carbapenem resistant enterobacteraciae (CRE).
Some of the characteristics of these MDRO are summarised in the table below
Summary of MDRO characteristics
|MDRO||Normal habitat||Infections||Mode of transmission|
|MRSA||Skin (nares, groin)||Skin, urinary tract, chest, wound||Contact – colonised or infected skin/ulcer
|ESBLs||Bowel||Urinary tract, wound, pneumonia||Contact with faecal or urine contaminated items. Contact with colonised wound/ulcer|
|VRE||Bowel||Urinary tract, wound, pneumonia||Contact as for ESBLs
|CRE||Bowel||Urinary tract, wound, pneumonia||Contact as for ESBLs
High prevalence rates of MDRO colonisation in long term and aged residential care facilities are frequently reported in the literature. Although MDRO are often introduced into a facility from a resident who has recently been in hospital or has had multiple courses of antibiotics, they can spread easily through ARC. This may be due to poor infection prevention and control (IPC) practices, poor facility design or inadequate number of toilets or merely through social contact between residents. However despite the high rates of MDRO in residential care, it does not appear that residents are at greater risk of infection with these organisms.
Residential care facilities can play their part in helping to reduce the spread of MDRO by having an effective infection prevention and control programme which includes the following specific to MDRO:
- the use of standard IPC precautions and adherence to good hand hygiene practices
- Additional IPC measures when indicated
- surveillance of infections
- antimicrobial stewardship e.g. reducing inappropriate use of antibiotics for asymptomatic bacteriuria.
- Informing the emergency department or ward of the resident’s MDRO colonisation if admitted to hospital. This is important because additional precautions may be necessary in the acute hospital setting.
The care of a resident with an MDRO in an ARC facility must reach a balance of the needs of the resident to live a normal life within their ‘home’ and the responsibility to the wider society to prevent further transmission of the MDRO, which contributes to the increase in antibiotic resistance.
Staff and colonised or infected residents should understand the methods of spread of the MDRO and use suitable precautions to break this chain of infection transmission. In many cases this will be the use of routine standard precautions, particularly hand hygiene.
A risk assessment for each resident should be undertaken and the precautions tailored to their risk factors for spread. For example, emptying and handling urinary catheters and bags increases the risk of spread of ESBLs and apron and gloves should always be worn for this task.
Most MDRO colonise the bowel so faecal incontinence is always a risk factor for transmission.
For some of the more resistant organisms such as VRE and CRE, it is advisable that the colonised resident has their own room and toilet facilities and that staff wear a gown/apron and gloves for all cares that involve direct contact with wounds, emptying catheter bags, toileting or other intimate cares.
By ensuring staff are informed, regularly use standard precautions and good hand hygiene practices and implement antibiotic stewardship, together we can help reduce the rate of increase in MDRO in our society.
- Ministry of Health. 2007. Guidelines for the Control of Multidrug-resistant Organisms in New Zealand. Wellington: Ministry of Health
Ruth Barratt RN, BSc, MAdvPrac (Hons)
Independent Infection Prevention & Control Advisor