1.
HEALTH CARE ASSOCIATED
INFECTIONS
CREATING DRUG RESISTANCE ATLAS
(INCORPORATING CDC GUIDELINES)
Dr.T.V.Rao MD
3/21/2016 Dr.T.V.Rao MD 1

2.
Healthcare-associated infections
•Healthcare-
associated
infections (HAIs)
are a major, yet
often preventable,
threat to patient
safety
3/21/2016 Dr.T.V.Rao MD 2

3.
A question to
Many
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4.
Hospital Breed Many Infections
How good we are to detect makes
difference?
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5.
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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6.
The report includes data reported to Hospital
Infection control committee from the following
locations:
• CLABSI: intensive care units, neonatal intensive care unit,
• and wards
• ■ CAUTI: intensive care units and wards
• ■ C difficile: all inpatient locations in the facility, with the
• exception of the neonatal intensive care units and well-baby
• locations
• ■ MRSA bacteremia: all inpatient locations in the facility
3/21/2016 Dr.T.V.Rao MD 6

7.
Microbiology Departments should
Document on pathogens
•The Antibiotic
documentation includes
resistance data for 31 bug-
drug profiles (or
phenotypes, pathogen-
antibiotic combinations
that are used to describe
the bacteria’s resistance to
a specific drug(s).3/21/2016 Dr.T.V.Rao MD 7

8.
These phenotypes include:
•Methicillin-resistant
Staphylococcus aureus
(MRSA)
•Carbapenem-resistant
Enterobacteriaceae
(CRE)
•Multidrug-resistant
Pseudomonas
aeruginosa
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9.
HOSPITALS CAN CREATE
ANTIBIOTIC
RESISTANCE ATLAS
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10.
Why we Need to Create an Atlas
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11.
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).
• Less severe infections are common and occur outside of non-acute
healthcare settings and in the community
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12.
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13.
Phenotype Analytical Definitions
Methicillin-Resistant Staphylococcus
aureus (%R)
•Analytical Definition:
Staphylococcus aureus
that has tested
resistant (R) to at least
1 of the following:
methicillin,
oxacillin, cefoxitin
3/21/2016 Dr.T.V.Rao MD 13

14.
MRSA with Community-associated
Resistance Pattern (%R)
• Any MRSA that has tested
resistant (R) to erythromycin
and sensitive (S) to
trimethoprim-
sulfamethoxazole 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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15.
Documents to Create Atlas
• Linezolid-Resistant MRSA (%R)
• MRSA 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 (%I)
• MRSA that has tested intermediate (I) to vancomycin
• Daptomycin-Resistant MRSA (Resistant or Intermediate) (%R*)
• MRSA that has tested non-susceptible (NS) to daptomycin
3/21/2016 Dr.T.V.Rao MD 15

16.
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 antibiotics. Some
strains are resistant to nearly all or all antibiotics.
3/21/2016 Dr.T.V.Rao MD 16

17.
Phenotype Analytical Definitions
•Carbapenem-Resistant
Acinetobacter spp.
(%R*)
•Any Acinetobacter spp.
that has tested either
intermediate (I) or
resistant (R) to at least
one of the following:
imipenem,
meropenem,doripenem3/21/2016 Dr.T.V.Rao MD 17

18.
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
3/21/2016 Dr.T.V.Rao MD 18

19.
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 Enterobacteriaceae (CRE).
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20.
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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21.
MDR E.coli (%R)
•Any 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)
•4. Carbapenems (imipenem, meropenem, doripenem,
ertapenem)
•5. Piperacillin Group (piperacillin, piperacillin/tazobactam)3/21/2016 Dr.T.V.Rao MD 21

22.
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 nightmare bacteria
carbapenem-resistance Enterobacteriaceae (CRE).
• Find more information about carbapenem-resistant Enterobacteriaceae in the
ARThreat Report.
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23.
Phenotype Analytical
Definitions
•Carbapenem-Resistant Enterobacter spp. (%R)
•Any Enterobacter spp. that has tested resistant (R) to at
least 1 of the following: imipenem, meropenem,
doripenem, ertapenem
•Extended-Spectrum Cephalosporin-Resistant
Enterobacter spp. (%R)
•Any Enterobacter spp. that has tested resistant (R) to at
least 1 of the following: ceftriaxone, ceftazidime,
cefepime, cefotaxime3/21/2016 Dr.T.V.Rao MD 23

24.
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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25.
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, such as
carbapenems.
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26.
Phenotype Analytical Definitions
Carbapenem-Resistant Klebsiella spp.
(%R)
• Any Klebsiella oxytoca or Klebsiella
pneumoniae that has tested resistant (R)
to at least 1 of the following: imipenem,
meropenem,doripenem, ertapenem
• Extended-Spectrum Cephalosporin-
Resistant 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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27.
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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28.
Pseudomonas
aeruginosa• Pathogen Overview
• • Pseudomonas aeruginosa is a common cause of healthcare-associated
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 ARThreat Report
3/21/2016 Dr.T.V.Rao MD 28

29.
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 of the following: cefepime and ceftazidime
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30.
MDR Pseudomonas
aeruginosa (%R)
• Any 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, doripenem)
• 5. Piperacillin Group (piperacillin, piperacillin/tazobactam)
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31.
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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32.
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 healthcare-associated
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 onVancomycin-resistant Enterococcus faecium in the ARThreat
Report.
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33.
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 that has
tested non-susceptible (NS) to
daptomycin
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34.
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 onVancomycin-resistant Enterococcus faecalisin the AR
Threat Report
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35.
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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36.
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 healthcare-associated
infections according to a 2011 national
prevalence survey performed by CDC.
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37.
Understanding Coagulase
Negative Staphylococcus
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38.
Phenotype Analytical
Definitions
• Vancomycin-Resistant Coagulase-
Negative 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 Staphylococci
that has tested resistant(R) to
vancomycin
3/21/2016 Dr.T.V.Rao MD 38

39.
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
Enterobacteriaceae in the ARThreat Report.
3/21/2016 Dr.T.V.Rao MD 39

40.
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: imipenem,
meropenem,
doripenem, ertapenem
3/21/2016 Dr.T.V.Rao MD 40

41.
3/21/2016 Dr.T.V.Rao MD 41

42.
In spite of Many Developments Hand
Washing still continues to be great boon
to stop spread of Hospital Associated
Infections
3/21/2016 Dr.T.V.Rao MD 42

43.
Hand Washing Saves Many
Lives
Are we Practising
3/21/2016 Dr.T.V.Rao MD 43

44.
FOR MORE INFORMATION ABOUTTHE AR
ATLAS,VISIT:
HTTP://WWW.CDC.GOV/HAI/SURVEILLANCE
3/21/2016 Dr.T.V.Rao MD 44

45.
Attention of Viewers• I am thankful to many in the world who made me to achieve my desired goals faster than I thought, having > 3-5 million
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create interest in Medical, 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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3/21/2016 Dr.T.V.Rao MD 45

46.
•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
3/21/2016 Dr.T.V.Rao MD 46