Chp 21 Multidrug-Resistant Organism Infection Disorder

Methicillin-resistant Staphylococcus aureus TREATMENT MEDICATIONS

(MRSA is vancomycin (Vancocin) administered either IV or orally. The trough level (blood sample drawn after a dose is given but immediately before the next dose) should be monitored at least weekly to avoid toxic doses and maintain therapeutic levels.) Vancomycin, Linezolid, Daptomycin, Tigecycline, Clindamycin, Sulfamethoxazole-trimethoprim

Acinetobacter TREATMENT MEDICATIONS

(Many different antimicrobial classes are used to treat MDR Acinetobacter; however, before treatment begins, susceptibility testing must occur because antibiotic resistance has increased over the last decade.) Ampicillin-sulbactam, Imipenem/Cilastatin, Meropenem, Tobramycin, Amikacin, Tigecycline, Polymyxin B, Polymyxin E, Colistin, Minocycline, Doxycycline

Clostridium difficile TREATMENT MEDICATIONS

(causative antibiotic must be stopped. 20% of patients, will resolve within 2 to 3 days of discontinuing the antibiotic to which the patient was previously exposed. Oral vancomycin is considered the first-line agent for the treatment of an initial episode of severe C. diff ) • • Probiotics (Probiotics (live bacteria and yeasts) are another treatment that is used supplementally.) Vancomycin, Fidaxomicin, Metronidazole

Vancomycin-resistant enterococci TREATMENT MEDICATIONS

(infections are often difficult to treat and may require multiple antibiotics for treatment because most VRE isolates are resistant to penicillin and ampicillin. Susceptibility testing is recommended to verify the activity of the antimicrobial agent being used.) Quinupristin-dalfopristin, Linezolid, Daptomycin, Tigecycline

Answer: A, C, and E Rationale: Isolation Precautions • Isolation precautions MUST be used for patients with MRSA, VRE, C. diff and Acinetobacter. • Hand hygiene MUST be performed before healthcare workers put on isolation gowns and gloves. • Isolation gowns MUST be tied at the neck and waist to effectively prevent bacteria transmission. • Isolation gowns and gloves MUST be removed before the healthcare worker leaves the isolation patients room. • Hand hygiene MUST be performed before the healthcare worker leaves the isolation patient room. • Hand hygiene for C. diff requires the use of soap and water, not alcohol based sanitizers, to physically remove the spores

A nursing preceptor is observing a newly hired nurse caring for a patient with C. diff. What actions indicate correct isolation technique by the new nurse? (Select all that apply.) A. Discarding the isolation gown prior to leaving the room B. Discarding the isolation gown in a trash can by the sink outside the room C. Washing hands with soap and water immediately before exiting the room D. Washing hands with alcohol-based cleanser immediately before exiting the room E. Wearing the gown tied at the neck and waist

After three or more surveillance tests show clearance CORRECT. Discontinuation of contact precautions for MRSA clients may occur when clearance of the organism has been documented with three or more surveillance tests. Retesting patients to document clearance is commonly done 3 to 4 months after the last positive test result. However, some institutions consider MRSA-colonized patients to be colonized indefinitely.

After several days of intravenous treatment, Mr. Nguyen is asking when he will no longer need to be on contact precautions. What statement by the nurse is correct? After 10 days of IV vancomycin administration After three or more surveillance tests show clearance Until discharge For the rest of his life

Sterile swab; anterior nares CORRECT. The most common location to obtain a specimen for MRSA colonization is the anterior nares. Use of a sterile swab is the preferred collection method. Intradermal injection on the inner aspect of the arm would be used to administer a PPD to determine whether an individual had tuberculosis. A blood sample could be used to ascertain serum glucose level or other specific testing parameters. Examination of the urethral meatus would be needed if one was trying to determine the presence of genitourinary infection. An imaging study, specifically a chest x-ray, would reveal information relative to the respiratory and cardiac systems.

Based on your admission assessment, the nurse identifies that Mr. Nguyen should be screened for MRSA. Which method would the nurse use to obtain a specimen, and from which anatomical location would the specimen be obtained to show colonization? Intradermal injection; inner aspect of arm Sterile swab; anterior nares Blood specimen; venous access Imaging study; chest x-ray

Answer: A and C Rationale: The goal of transitional care is to have the patient safely transition out of the hospital. Timely follow-up with care providers is essential. Nutrition and physical therapy follow-up would be important if there were mobility or eating problems which are not evident with Mr. Brown at this time. Follow-up in the ED should be avoided unless there is an emergency.

Important transitional care plans for Mr. Brown include which of the following? (Select all that apply.) A. Follow-up with a home-care nurse B. Follow-up with a physical therapist C. Follow-up with his healthcare provider D. Follow-up with the emergency department E. Follow-up with a nutritionist

Client is at risk for increased morbidity and mortality as a result of HA-MRSA diagnosis.

In reviewing a client's hospital chart, the nurse notes that in addition to multiple comorbidities, the client has been diagnosed with hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA). Based on this finding the nurse determines that: A shortened hospital stay will be anticipated. The clinical diagnosis of HA-MRSA will have no direct effect on client's outcome. It is likely that the client will require blood transfusions for stabilization. Client is at risk for increased morbidity and mortality as a result of HA-MRSA diagnosis.

Answer: E A. Contact B. Airborne C. Vehicle D. Vectorborne

Infections can be transmitted by: A. Contact B. Airborne C. Vehicle D. Vectorborne E. All of the above

History of type 2 diabetes, controlled with medication, Resides in a long-term care facility, Surgery required to correct the hip fracture CORRECT. Risk factors for MRSA include history of type 2 diabetes, residence in a long-term care environment where clients have frequent contact with multiple people, and invasive medical or surgical procedures.

Mr. Nguyen is an older adult admitted to the hospital from a long-term care facility for treatment of a hip fracture that occurred during a fall. Upon admitting the client to the surgical unit, the nurse obtains assessment data based on a provided client history. Which factors, if noted in Mr. Nguyen's history, would increase the risk of him having methicillin-resistant Staphylococcus aureus (MRSA)? Select all that apply. History of type 2 diabetes, controlled with medication He is a widower Resides in a long-term care facility Surgery required to correct the hip fracture Client is male

Initiation of a decolonization process using mupirocin ointment in both nares should be instituted. CORRECT. Decolonization treatment for MRSA is provided intranasally with mupirocin ointment. When using vancomycin as a therapy treatment, use of peak/trough level monitoring is required to verify that dosages are both safe and therapeutic. Patients taking linezolid should avoid foods with high tyramine contents, not sugar substitutes. The client taking clindamycin is at risk for diarrhea and C-diff infection.

Mr. Nguyen is going to be medicated for MRSA. Based on the information provided, which pharmacological statement is accurate about MTSA treatments? It is not necessary to obtain a peak level for vancomycin as the dosage indicated for this type of therapy is at the lower therapeutic range. While the client is taking linezolid, he should refrain from using sugar substitutes. There is an increased likelihood for the client to experience constipation while being treated with clindamycin. Initiation of a decolonization process using mupirocin ointment in both nares should be instituted.

Determination of trough level prior to start of scheduled dose, Patency of intravenous access site CORRECT. Vancomycin is the most commonly initiated IV therapy for MRSA. When hanging ongoing vancomycin therapy, it is important to know the trough level prior to initiation of dosing. If the trough level is too high, then the dosage may be adjusted or held to prevent potential nephrotoxicity. A peak level is the drug's highest serum level and would not be obtained prior to the start of the scheduled dose. Although the client's weight is an important baseline factor for dosing, it is not necessary to include the client's current weight. It is important to note that the intravenous site can be accessed since the medication is an irritant. The client's hydration status is not pertinent.

Mr. Nguyen progresses through hospitalization and following the surgical revision, the surgical site becomes positive for MRSA. Based on this new finding, the provider initiated intravenous therapy of vancomycin. Mr. Nguyen has been on this therapy for 5 days. Which assessment data should the nurse evaluate before hanging the next scheduled dose of therapy? Select all that apply. Client's current weight Documentation of peak level prior to start of scheduled dose Determination of trough level prior to start of scheduled dose Patency of intravenous access site Hydration status

Contact precaution CORRECT. Use of contact precaution is the mainstay for clients who are positive for MRSA. Bloodborne precaution is not needed since MRSA is typically located in the nares. Although a private room is preferred, a client who has MRSA can be placed with another client who has the same infection. A laminar flow room is appropriate for a client who has tuberculosis or another serious airborne infectious disease.

Test results confirm that Mr. Nguyen is positive for MRSA. Based on this result, the nurse should institute which type of precaution? Contact precaution Bloodborne precaution Placement in a private room with an antechamber washroom Placement in a laminar flow room

Answer: D Rationale: Patients colonized or infected with MDR organisms are placed in private rooms when available or placed in a room with other patients colonized or infected with the same organism. Patients with different MDR infections are not cohorted together.

The charge nurse is making assignments for the next shift. In looking at patient combinations, the nurse recognizes that a patient with an MRSA wound infection can be located in the same room with what other patient? A. A patient who has an Acinetobacter wound infection B. A patient who has C. diff C. A patient who has an MRSA wound infection and has VRE D. A patient with MRSA bacteremia

"Antibiotics can be given, but it is equally important to make sure that no complications arise due to the presence of MRSA."

The client tells the nurse, "Who cares if I have methicillin-resistant Staphylococcus aureus (MRSA)? Just give me some antibiotics and everything will be okay." What is the nurse's best response to this client statement? "The correct antibiotic therapy will clear up this infection, so there is no need to worry." "Antibiotics can be given, but it is equally important to make sure that no complications arise due to the presence of MRSA." "Using antibiotics more frequently will only lead to further antibiotic resistance." "As long as you are asymptomatic, you don't need any antibiotic therapy."

Answer: A, B, and D A. Tachycardia B. Tachypnea D. Abnormal WBC

The following are components of the inflammatory process: (Select all that apply.) A. Tachycardia B. Tachypnea C. Normothermia D. Abnormal WBC

Answer: The nurse should assess Mrs. Smith first. She appears to be dehydrated from her diarrhea and needs prompt treatment with fluids. Mr. Thomas also needs prompt treatment for a suspected MRSA systemic infection but appears to be compensating at present with a low but normal BP.

The nurse has received reports on two patients. Who should the nurse see first and why? Mr. Thomas is a 38-year-old male admitted for evaluation of fever, lethargy, and fatigue. He suffered a right lower extremity wound at his construction work site a week ago. Vital signs are: Temp 101.5 Pulse 112 Resp 26 BP 110/60 Significant diagnostic findings: WBC 1400 Chest x-ray unremarkable Wound on right lower leg painful, hot, red with purulent drainage Mrs. Smith is a 55-year-old female presently complaining of severe diarrhea over the past several days and extreme fatigue. Patient was recently treated with antibiotics for a UTI. The patient has a past medical history of hypertension and DM type II. Vital signs are: Temp 99.5 Pulse 116 Resp 20 BP 90/55 Significant diagnostic findings: C diff toxins in her stool

Answer: D Rationale: The use of antiperistaltic agents should be avoided because they may delay clearance of toxins from the colon and exacerbate toxin-induced colonic injury or precipitate ileus (an intestinal obstruction that results in the failure of intestinal contents to pass through) and toxic megacolon (a life-theatening complication of inflammatory bowel disease that causes rapid dilation of the large intestines which results in septic shock). Flagyl is the treatment of choice. Probiotics help preserve normal gut flora. Fluids are necessary to avoid potential dehydration due to diarrhea.

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. Encourage fluid intake D. Imodium

Answer: A, B, and D Rationale: Risk factors for MDR Acinetobacter baumannii infections and colonization include recent surgery, central venous catheters, tracheostomy, mechanical ventilation, enteral feedings, exposure to antimicrobial agents, and underlying severity of illness. Other risk factors include prolonged hospitalization, intensive care unit admissions, prior hospitalizations, and nursing home residence.

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

Answer: B Rationale: The risk factors for VRE are very similar to MRSA. They include prolonged hospital stays, people with weakened immune systems (such as patients in intensive care units, transplant patients and cancer patients, especially hematological malignancies), prolonged exposure to antibiotics (especially exposure to vancomycin and cephalosporins), and invasive procedures and devices.

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

Answer: C Rationale: The most frequent clinical manifestations of Acinetobacter baumannii infections are ventilator associated pneumonia and blood stream infections. Toxic megacolon and peritonitis are complications of C. diff. Wound infections are seen with MRSA.

The nurse monitors for which clinical manifestation in the patient diagnosed with A. baumannii? A. Toxic megacolon B. Wound infections C. Pneumonia D. Peritonitis

Answer: D Rationale: MRSA causes more serious infections skin and soft tissue infections resulting in red, edematous, draining wounds — all signs of infection. Hyperglycemia, tachcardia, and tachypnea are systemic, not local signs of infection.

The nurse monitors for which clinical manifestations of MRSA in Mr. Brown's wound infection? A. Hyperglycemia B. Tachycardia C. Tachypnea D. Red, edematous, draining wound

Answer: A, B, and C Rationale: Severe C. diff infections lead to complications such as: • volume depletion (hypovolemia) • renal insufficiency • electrolyte imbalances (hypo/hyperkalemia, hypo/hypernatremia) • hypoalbuminemia (low serum albumin levels) • hypotension (low blood pressure) • peritonitis (inflammation of the peritoneum) • paralytic ileus (intestinal obstruction) • toxic megacolon (rapid dilation of the large intestines) • fulminant pseudomembranous colitis • sepsis • death • Pneumonia and wound infections are not complications associated with C. diff

The nurse monitors for which complication in the patient diagnosed with C. diff? (Select all that apply.) A. Increased BUN and creatinine B. Abnormal electrolytes C. Hypoalbuminemia D. Pneumonia E. Extensive wound infection

Isolation gown and gloves are removed as the student enters the hallway, Isolation gown is secured at the waist only, Hand hygiene performed after the student leaves the room CORRECT. To prevent transmission, the nurse must (1) Perform hand hygiene before putting on isolation gowns and gloves; (2) Secure isolation gowns at the neck and waist to effectively prevent bacteria transmission; (3) Remove gowns and gloves before the leaving the isolation patient's room; and (4) Perform hand hygiene before the healthcare worker leaves the isolation patient's room.

The nurse observes a student in Mr. Nguyen's room. Which situations requires correction by the nurse? Select all that apply. Isolation gown and gloves are removed as the student enters the hallway. Hand hygiene performed before the isolation gown and gloves are applied. Isolation gown is secured at the waist only. Hand hygiene performed after the student leaves the room. Student checks Mr. Nguyens identification band before giving a medication.

Answer: B Rationale: Vancomycin can cause nephrotoxicity which is evidenced by decreasing urine output and increasing BUN/creatinine. Pain at the incision site is not unexpected as long as it does increase significantly. Depression and decreased appetite should be evaluated as they may be signs of patient distress, but they are not the priority.

The nurse should intervene immediately if Mr. Brown is noted to have which of the following symptoms? A. Depression B. Oliguria C. Decreased appetite D. Pain at the incision site

Answer: A, C, and D Rationale: Risk factors for HA-MRSA include current or recent hospitalization and residing in a long-term care facility, thus increasing risk of exposure, invasive procedures or medical devices such as urinary catheters or intravenous lines that create a portal for the entry, and recent or long-term broad spectrum antibiotic use allowing bacteria to become resistant to a specific antibiotic. The recent surgical procedure provides a potential focus for the infection.

The nurse understands Mr. Brown is at increasedrisk for a MRSA infection because of whichfactor(s)? (Select all that apply.) A. His recent hospitalization B. His history of atrial fibrillation C. His recent surgical procedure D. His residence in a long-term care facility E. His current use of the medication Coumadin

Answer: A Rationale: MRSA is the only MDR organism discussed in this chapter that is readily seen in the community as well as the healthcare setting

The nurse understands which MDR organism is seen in healthy patients living in the community? A. MRSA B. VRE C. C. diff D. Acinetobacter

Answer: C C. Skin

What is the largest organ in the immune system? A. Spleen B. Thymus C. Skin D. Mucus membranes

Answer: A Rationale: The best treatment of multidrug resistant organisms begins with prevention, hand hygiene. The declining rates of some MDR infections have been attributed to the use of alcohol-based hand rubs and improved hand hygiene programs.

What is the priority intervention to prevent the spread of MDR organisms? A. Hand washing B. Diagnostic cultures C. Isolation precautions D. Antibiotic administration

Hand hygiene

What nursing action is considered to be a best-practice in stopping the spread of methicillin-resistant Staphylococcus aureus in the clinical setting? Vital sign assessment Changing the client's water pitcher Hand hygiene Changing the first post-operative dressing using sterile technique

Answer: A, B, C, and E Rationale: Risk factors for HA-MRSA include current or recent hospitalization and residing in a long-term care facility, thus increasing risk of exposure, invasive procedures, or medical devices such as urinary catheters or intravenous lines that create a portal for the entry and recent or long-term broad spectrum antibiotic use, allowing bacteria to become resistant to a specific antibiotic.

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

Client has intravenous line. Client has frequently used antibiotic therapy. Client just had a pacemaker placed.

Which findings alert the nurse to the possibility of a hospitalized client developing hospital-acquired methicillin-resistant Staphylococcus aureus? Select all that apply. Client has intravenous line. Client has frequently used antibiotic therapy. Client is on a full-liquid diet. Client just had a pacemaker placed. Client is allergic to sulfa.

Answer: B Rationale: It is essential that patients completely finish their antibiotics as prescribed to avoid reoccurrence and potential development of antibiotic resistance. Reporting hyperglycemia is appropriate as it may signal infection. Being careful about antibiotics is appropriate antibiotic stewardship and never wanting to go to the hospital again is an appropriate sentiment.

Which statement by Mr. Brown indicates the need for further teaching? A. "I need to be careful about the antibiotics I take." B. "I'll stop taking my antibiotics when I'm feeling better." C. "I never want to go to the hospital again." D. "I'll call my doctor if my blood sugar goes up."

Vancomycin therapy will be initiated via parenteral route.

Which statement indicates that the nurse understands pharmacological treatment of hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA)? Ampicillin is the most likely drug that the physician will order. Alternative therapies should be used for clients who have allergies to penicillin as this is the drug of choice for MRSA. Vancomycin therapy will be initiated via parenteral route. Serum blood work evaluating the client's uric acid level will be required during the course of therapy.

Strict handwashing utilized in all client care interactions CORRECT. While waiting for the test results, the nursing staff should always maintain strict handwashing techniques as the best prevention strategy. There is no need for reverse isolation as there is no current evidence of immunosuppression. There is no confirmed reason at present to anticipate that the use of PPE will be warranted during the client's hospitalization.

While the nursing staff is waiting for test results, which method would be instituted as part of a prevention strategy? Initiation of reverse isolation Two shower applications of Kwell shampoo Use of Personal Protective Equipment (PPE) throughout the course of hospitalization Strict handwashing utilized in all client care interactions

Vector borne

also an indirect mode of transmission that occurs when a vector, an organism that transmits a pathogen, bites or infects a person

Vehicle

an indirect mode of transmission that occurs when a disease-carrying agent touches a person's body or is ingested

Airborne

ccurs when pathogens are carried through the air.

Contact

occurs when a person or object comes in contact with a pathogen.

INTRODUCTION infection

• A susceptible host and a mode of transmission • • Required for a pathogen to cause a disease • A transport mechanism • • Required for infection to be transmitted • Routes of transmission • Contact • Airborne • Vehicle • Vector borne

Routes of transmission

• Contact • Airborne • Vehicle • Vector borne

Teaching

• Contact-isolation precautions and hand washing (see Evidence-Based Practice) Teach patient and visitors the importance of wearing gowns and gloves when entering the room and removing the gowns and gloves when exiting the patient's room; also teach them the importance of performing hand hygiene after removing the gown and gloves. • Take antibiotics as prescribed. Antibiotics should be taken as prescribed, and the patient should finish the course of antibiotics to prevent the reoccurrence of MDR infections. • Clinical manifestations of infection It is important that the patient and family are able to recognize the signs and symptoms of infection. • Sun protection Be aware of antibiotics such as tetracyclines that create sun sensitivities. Avoid prolonged sun exposure, wear sunscreen and appropriate covering clothing

Acinetobacter baumannii

• Epidemiology • • 1st identified in 1911 named Micrococcus calco-aceticus • • 1950s known as acinetobacter • Pathophysiology • • Nonfermentative, aerobic, gram-negative coccobacillus • • Naturally inhabits water, soil, animals, and humans (Multidrug-resistant Acinetobacter is a nonfermentative, aerobic, gram-negative coccobacillus that naturally inhabits water, soil, animals, and humans.) • Clinical Manifestations • • Infect or colonize many body sites (Acinetobacter can infect or colonize many body sites. Typical sites of colonization and infection are the respiratory tract, blood, pleural fluid, peritoneum, urinary tract, surgical wounds, central nervous system (CNS), skin, and eyes. The most frequent clinical manifestations of A. baumannii infections are ventilator-associated pneumonia and bloodstream infections.) • Complications • • Increase mortality, morbidity, length of hospitalization, and length of ventilator days (Many complications are associated with MDR Acinetobacter infections. They increase mortality, morbidity, length of hospitalization, and length of ventilator days; These infections also prolong an ICU stay by 6 days, with the median duration of hospitalization being 18 days)

Vancomycin-resistant enterococci (VRE)

• Epidemiology • • 3rd most common organisms seen in nosocomial infections (Enterococci are bacteria that normally live in the gastrointestinal tract and the female genital tract and are also found in the environment in soil, water, and food. They are the third most common organisms seen in nosocomial infections. Traditionally, Enterococci have been considered low-grade pathogens; however, in the 1990s, they surfaced as an increasingly important cause of nosocomial infections. Enterococci are facultatively anaerobic (organisms that use aerobic metabolism if oxygen is present but can switch to anaerobic metabolism if oxygen is absent) gram-positive cocci. Vancomycin-resistant Enterococci (VRE) were first reported in 1986 in Europe.) • Pathophysiology • • Remain viable on environmental surfaces for 7 days to 2 months (They are also difficult to control because treatment options may be limited. A polypharmacological approach may be necessary.) • Clinical Manifestations • • Back pain, pain on urination, sensation of needing to urinate, and fever • • Wound infections typically present as red and hot (Enterococci commonly cause urinary tract infections (UTIs), peritonitis (intra-abdominal and pelvic wound infections), and bacteremias; thus, clinical manifestations vary depending on the site of infection. Classic signs of UTI are back pain, pain on urination, the sensation of needing to urinate, and fever. Wound infections typically present as red and hot and, at times, with purulent drainage. Bacteremias present with signs of sepsis: tachycardia, hypotension, and fever.) • Complications • • Growing list of resistance to antimicrobial agents • • Emergence of vancomycin-resistant S aureus • Risk Factors • • Prolonged hospitalization • • Weakened immune system • • Prolonged antibiotic exposure • • Invasive procedures/medical devices • • Comorbid conditions

Clostridium difficile

• Epidemiology • • Most common cause of antibiotic-associated diarrhea in the U.S. (Clostridioides difficile is the most common cause of antibiotic-associated diarrhea in the United States, responsible for 12% of all hospital-acquired infections.) • Pathophysiology • • Spore-forming, gram-positive anaerobic bacillus • • Transmitted through the oral fecal route (Clostridioides difficile is a spore-forming, gram-positive anaerobic bacillus. Clostridioides difficile spores are resistant to many types of disinfectants, heat, and dryness; transmitted through the oral-fecal route. This occurs when a pathogen from feces is introduced into the oral cavity of a host. Clostridioides difficile is almost exclusively found in healthcare settings; As the C. diff infection worsens, purulent and necrotic debris accumulates and forms pseudomembranes (thin tissue layer covering the surface of the epithelium)) • 3 ways patients exposed in hospitals • • Contact with health-care workers' contaminated hands • • Contact with the contaminated environment • • Direct contact with a patient with a C diff infection • Clinical manifestations • • Range from symptomless to fulminant fatal pseudomembranous colitis (People who develop C. diff infections test positive for C. diff toxins in their stool. Although patients may be asymptomatic, the most common clinical manifestation is mild to moderate diarrhea.) • Complications • • Volume depletion (hypovolemia) and hypotension (low blood pressure) • • Renal insufficiency • • Electrolyte imbalances (hypo-/hyperkalemia, hypo-/hypernatremia) • • Hypoalbuminemia (low serum albumin levels) • • Peritonitis (inflammation of the peritoneum) • • Paralytic ileus (intestinal obstruction) • • Toxic megacolon (rapid dilation of the large intestines) • • Fulminant pseudomembranous colitis • • Sepsis • • Death treatments for severe C. diff infections that progress to fulminant pseudomembranous colitis, paralytic ileus, toxic megacolon, or sepsis

Methicillin-resistant Staphylococcus aureus

• Epidemiology • • S aureus (Staphylococcus aureus (S. aureus) is a common asymptomatic pathogen and is considered normal bacterial flora of humans.) • Pathophysiology • • Aerobic, gram-positive, nonsporulating coagulase-positive bacterium (aerobic, gram-positive, nonsporulating (does not make spores capable of reproduction), coagulase-positive bacterium (produces the enzyme coagulase, which helps convert fibrinogen to fibrin) Because it is a coagulase bacterium, MRSA is coated with a fibrin wall that resists phagocytosis, making the bacterium more virulent, thus enabling it to protect itself from host defense mechanisms) • Clinical Manifestations • • Minor skin infections (commonly include minor skin infections, including pimples, abscesses, sties, and impetigo; causes more serious infections, including pneumonia, skin and soft tissue infections, surgical-site infections, and bloodstream infections) • Complications • • Increased morbidity and mortality rates • • Septic shock Because MRSA is resistant to numerous antibiotics, infections can often be difficult to treat and can cause serious complications as well as widespread infection. Infections with MRSA are associated with increased morbidity and mortality rates highest mortality rates of 55.6% were observed among patients with MRSA-related septic shock. • Risk Factors for hospital acquired • • Current/recent hospitalization • • Residing in long-term care facility • • Invasive procedures/medical devices • • Recent antibiotic use • • Weakened immune system • • Comorbid conditions • • Dialysis devices • • Gastrointestinal disorders • Risk Factors for Community-Acquired • • Less than 2 years of age • • Athletes • • IV drug abusers • • Men who have sex with men • • Military personnel • • Prison inmates • • People living in shelters

Actions

• Hand hygiene To prevent the spread of MDR organisms: (1) alcohol-based cleansers are effective against nearly all MDR organisms, except C. diff; (2) physical hand washing with soap and water is necessary to remove C. diff. • Place the patient on contact-isolation precautions. To prevent the spread of MDR organisms • Administer medications as ordered: • Administer antibiotics. To treat infection of an MDR organism • Administer fever reducers. To decrease fever and complications associated with increased metabolic rate; also increases comfort • Administer pain medications. To decrease pain from wound or surgical-site infection • Administer IV fluids or encourage the patient to drink fluids. To rehydrate from loss of fluid secondary to diarrhea from C. diff infection or from infections with MDR organisms • Administer supplemental oxygen. To increase oxygen saturation secondary to MDR pneumonia • Administer chest physiotherapy. To mobilize secretions in patients with MDR pneumonia and to increase oxygen saturation • Encourage early mobilization. To decrease the risk of atelectasis secondary to MDR pneumonia and promote overall patient conditioning • Stop administration of causative antimicrobial agent with a C. diff infection. To stop/decrease C. diff-associated diarrhea • Perform wound care as ordered. To treat wound or surgical-site infection and promote wound healing • Cleanse perineum and apply moisture barriers. To prevent skin breakdown or IAD secondary to C. diff- associated diarrhea • Use fecal diversion or containment systems in the stool-incontinent patient. To prevent skin breakdown and increase comfort in C. diff patients • Encourage family visits and the use of the telephone and television. To prevent depression in a patient in isolation with an MDR-organism infection

Assessments

• Vital signs Increased body temperature is an immune response to an infection. A person's body temperature rises to try to kill the bacteria or virus that is causing the infection. Increased heart rate can occur due to fever and metabolic rate increases or hypovolemia. Tachypnea can occur secondary to pneumonia from infection with an MDR organism. Tachypnea is also caused secondary to a fever, which increases the metabolic rate, which then increases the work of breathing. Low blood pressure may indicate vasodilation due to systemic infection and hypovolemia. Hypovolemia can also occur secondary to fluid loss as a result of C. diff diarrhea. • Oxygen saturation Monitor the patient's oxygen saturation. Decreased oxygen saturation can be a symptom of pneumonia caused by an MDR organism. • Pain Pain is the fifth vital sign. Monitor patients for increased pain. Increased pain can be a sign of infection caused by an MDR organism; pain may also result from a fever. • Skin turgor and mucous membranes Decreased skin turgor and dry mucous membranes can result from dehydration secondary to a C. diff infection. • Urine output Decreased urine output is a sign of dehydration and can occur secondary to C. diff diarrhea or may indicate the presence of a systemic infection with an MDR organism. It can also occur as an adverse side effect of antibiotics used to treat the infection. • Wound or surgical sites An infected wound or surgical site caused by an MDR organism may be red, swollen, painful, and warm to the touch and may have purulent drainage. • Bowel movement frequency and consistency Increased bowel movement frequency can result in dehydration. When a person has a C. diff infection, the bacteria proliferate and cause the release of toxins, resulting in an inflammatory response in the colon, which causes fluid to be secreted into the colon, resulting in diarrhea. • Skin integrity Monitor skin integrity to assess for skin breakdown or incontinence-associated dermatitis (IAD) secondary to C. diff diarrhea. • Laboratory tests • White blood cell (WBC) count An increased WBC count is seen as part of the immune response; a large increase in WBCs may occur in C. diff infections. • Serum creatinine level Increased creatinine levels can occur when a patient is dehydrated or has an adverse reaction to antibiotic treatment, signaling decreased renal function. • Electrolyte and albumin levels Electrolyte and albumin levels may be decreased or increased secondary to dehydration from a C. diff infection or any MDR-organism infection.

Epidemiology (A. baumannii)

• • 1st identified in 1911 named Micrococcus calco-aceticus • • 1950s known as Acinetobacter

Epidemiology (VRE)

• • 3rd most common organisms seen in nosocomial infections (Enterococci are bacteria that normally live in the gastrointestinal tract and the female genital tract and are also found in the environment in soil, water, and food. They are the third most common organisms seen in nosocomial infections. Traditionally, Enterococci have been considered low-grade pathogens; however, in the 1990s, they surfaced as an increasingly important cause of nosocomial infections. Enterococci are facultatively anaerobic (organisms that use aerobic metabolism if oxygen is present but can switch to anaerobic metabolism if oxygen is absent) gram-positive cocci. Vancomycin-resistant Enterococci (VRE) were first reported in 1986 in Europe.)

Pathophysiology (MRSA)

• • Aerobic, gram-positive, nonsporulating coagulase-positive bacterium (aerobic, gram-positive, nonsporulating (does not make spores capable of reproduction), coagulase-positive bacterium (produces the enzyme coagulase, which helps convert fibrinogen to fibrin) Because it is a coagulase bacterium, MRSA is coated with a fibrin wall that resists phagocytosis, making the bacterium more virulent, thus enabling it to protect itself from host defense mechanisms)

Clinical Manifestations (VRE)

• • Back pain, pain on urination, sensation of needing to urinate, and fever • • Wound infections typically present as red and hot (Enterococci commonly cause urinary tract infections (UTIs), peritonitis (intra-abdominal and pelvic wound infections), and bacteremias; thus, clinical manifestations vary depending on the site of infection. Classic signs of UTI are back pain, pain on urination, the sensation of needing to urinate, and fever. Wound infections typically present as red and hot and, at times, with purulent drainage. Bacteremias present with signs of sepsis: tachycardia, hypotension, and fever.)

Diagnosis

• • Begins with detection (In an effort to contain outbreaks of VRE and MRSA, hospitals have initiated surveillance programs)

3 ways patients exposed in hospitals (C. diff)

• • Contact with health-care workers' contaminated hands • • Contact with the contaminated environment • • Direct contact with a patient with a C diff infection

Risk Factors for hospital acquired

• • Current/recent hospitalization • • Residing in long-term care facility • • Invasive procedures/medical devices • • Recent antibiotic use • • Weakened immune system • • Comorbid conditions • • Dialysis devices • • Gastrointestinal disorders

Complications (VRE)

• • Growing list of resistance to antimicrobial agents • • Emergence of vancomycin-resistant S aureus

Treatment

• • Hand hygiene (Hand Hygiene The best treatment of MDR organisms begins with prevention—hand hygiene.) • • Isolation (Patients in healthcare settings who are either colonized or infected with MDR organisms are placed on contact-isolation precautions (see Safety Alert: Isolation Precautions) to help reduce patient-to-patient spread of the organism within the hospital. Contact-isolation precautions include wearing gowns and gloves on entry to a patient's room, removing both the gown and gloves just prior to exiting, and performing proper hand hygiene before exiting. ) • Hand hygiene MUST be performed before healthcare workers put on isolation gowns and gloves. • Isolation gowns MUST be secured at the neck and waist to effectively prevent bacteria transmission. • Isolation gowns and gloves MUST be removed before the healthcare worker leaves the isolation patient's room. • Hand hygiene MUST be performed before the healthcare worker leaves the isolation patient's room.

Complications (A. baumannii)

• • Increase mortality, morbidity, length of hospitalization, and length of ventilator days (Many complications are associated with MDR Acinetobacter infections. They increase mortality, morbidity, length of hospitalization, and length of ventilator days; These infections also prolong an ICU stay by 6 days, with the median duration of hospitalization being 18 days)

Complications (MRSA)

• • Increased morbidity and mortality rates • • Septic shock Because MRSA is resistant to numerous antibiotics, infections can often be difficult to treat and can cause serious complications as well as widespread infection. Infections with MRSA are associated with increased morbidity and mortality rates highest mortality rates of 55.6% were observed among patients with MRSA-related septic shock.

Clinical Manifestations (A. baumannii)

• • Infect or colonize many body sites (Acinetobacter can infect or colonize many body sites. Typical sites of colonization and infection are the respiratory tract, blood, pleural fluid, peritoneum, urinary tract, surgical wounds, central nervous system (CNS), skin, and eyes. The most frequent clinical manifestations of A. baumannii infections are ventilator-associated pneumonia and bloodstream infections.)

Risk Factors for Community-Acquired

• • Less than 2 years of age • • Athletes • • IV drug abusers • • Men who have sex with men • • Military personnel • • Prison inmates • • People living in shelters

Clinical Manifestations (MRSA)

• • Minor skin infections (commonly include minor skin infections, including pimples, abscesses, sties, and impetigo; causes more serious infections, including pneumonia, skin and soft tissue infections, surgical-site infections, and bloodstream infections)

Epidemiology (C. diff)

• • Most common cause of antibiotic-associated diarrhea in the U.S. (Clostridioides difficile is the most common cause of antibiotic-associated diarrhea in the United States, responsible for 12% of all hospital-acquired infections.)

Pathophysiology (A. baumannii)

• • Nonfermentative, aerobic, gram-negative coccobacillus • • Naturally inhabits water, soil, animals, and humans (Multidrug-resistant Acinetobacter is a nonfermentative, aerobic, gram-negative coccobacillus that naturally inhabits water, soil, animals, and humans.)

Risk Factors (VRE)

• • Prolonged hospitalization • • Weakened immune system • • Prolonged antibiotic exposure • • Invasive procedures/medical devices • • Comorbid conditions

Clinical manifestations (C. diff)

• • Range from symptomless to fulminant fatal pseudomembranous colitis (People who develop C. diff infections test positive for C. diff toxins in their stool. Although patients may be asymptomatic, the most common clinical manifestation is mild to moderate diarrhea.)

Pathophysiology (VRE)

• • Remain viable on environmental surfaces for 7 days to 2 months (They are also difficult to control because treatment options may be limited. A polypharmacological approach may be necessary.)

A susceptible host and a mode of transmission

• • Required for a pathogen to cause a disease (A susceptible host usually has a weakened immune system or has had a breakdown in the body's defense mechanism)

A transport mechanism

• • Required for infection to be transmitted

Epidemiology (MRSA)

• • S aureus (Staphylococcus aureus (S. aureus) is a common asymptomatic pathogen and is considered normal bacterial flora of humans.)

Pathophysiology (C. diff)

• • Spore-forming, gram-positive anaerobic bacillus • • Transmitted through the oral fecal route (Clostridioides difficile is a spore-forming, gram-positive anaerobic bacillus. Clostridioides difficile spores are resistant to many types of disinfectants, heat, and dryness; transmitted through the oral-fecal route. This occurs when a pathogen from feces is introduced into the oral cavity of a host. Clostridioides difficile is almost exclusively found in healthcare settings; As the C. diff infection worsens, purulent and necrotic debris accumulates and forms pseudomembranes (thin tissue layer covering the surface of the epithelium))

Complications (C. diff)

• • Volume depletion (hypovolemia) and hypotension (low blood pressure) • • Renal insufficiency • • Electrolyte imbalances (hypo-/hyperkalemia, hypo-/hypernatremia) • • Hypoalbuminemia (low serum albumin levels) • • Peritonitis (inflammation of the peritoneum) • • Paralytic ileus (intestinal obstruction) • • Toxic megacolon (rapid dilation of the large intestines) • • Fulminant pseudomembranous colitis • • Sepsis • • Death treatments for severe C. diff infections that progress to fulminant pseudomembranous colitis, paralytic ileus, toxic megacolon, or sepsis

NURSING MANAGEMENT

•Assessment and analysis The clinical manifestations seen with MDR-organism infections are consistent with typical signs of infection: • Typical signs of infection • Fever • Tachycardia • Tachypnea • Hypovolemia • Diarrhea is the prominent manifestation of C. diff • MRSA wound infections can be red and warm with purulent drainage

MANAGEMENT MULTIDRUG-RESISTANT ORGANISMS

•Diagnosis • • Begins with detection (In an effort to contain outbreaks of VRE and MRSA, hospitals have initiated surveillance programs) • Treatment • • Hand hygiene (Hand Hygiene The best treatment of MDR organisms begins with prevention—hand hygiene.) • • Isolation (Patients in healthcare settings who are either colonized or infected with MDR organisms are placed on contact-isolation precautions (see Safety Alert: Isolation Precautions) to help reduce patient-to-patient spread of the organism within the hospital. Contact-isolation precautions include wearing gowns and gloves on entry to a patient's room, removing both the gown and gloves just prior to exiting, and performing proper hand hygiene before exiting. ) • Hand hygiene MUST be performed before healthcare workers put on isolation gowns and gloves. • Isolation gowns MUST be secured at the neck and waist to effectively prevent bacteria transmission. • Isolation gowns and gloves MUST be removed before the healthcare worker leaves the isolation patient's room. • Hand hygiene MUST be performed before the healthcare worker leaves the isolation patient's room.

MULTIDRUG-RESISTANT ORGANISMS

•Methicillin-resistant Staphylococcus aureus •Vancomycin-resistant enterococci • Clostridium difficile •Acinetobacter baumannii

TREATMENT MEDICATIONS

•Methicillin-resistant Staphylococcus aureus (MRSA is vancomycin (Vancocin) administered either IV or orally. The trough level (blood sample drawn after a dose is given but immediately before the next dose) should be monitored at least weekly to avoid toxic doses and maintain therapeutic levels.) Vancomycin, Linezolid, Daptomycin, Tigecycline, Clindamycin, Sulfamethoxazole-trimethoprim •Vancomycin-resistant enterococci (infections are often difficult to treat and may require multiple antibiotics for treatment because most VRE isolates are resistant to penicillin and ampicillin. Susceptibility testing is recommended to verify the activity of the antimicrobial agent being used.) Quinupristin-dalfopristin, Linezolid, Daptomycin, Tigecycline • Clostridium difficile (causative antibiotic must be stopped. 20% of patients, will resolve within 2 to 3 days of discontinuing the antibiotic to which the patient was previously exposed. Oral vancomycin is considered the first-line agent for the treatment of an initial episode of severe C. diff ) • • Probiotics (Probiotics (live bacteria and yeasts) are another treatment that is used supplementally.) Vancomycin, Fidaxomicin, Metronidazole •Acinetobacter (Many different antimicrobial classes are used to treat MDR Acinetobacter; however, before treatment begins, susceptibility testing must occur because antibiotic resistance has increased over the last decade.) Ampicillin-sulbactam, Imipenem/Cilastatin, Meropenem, Tobramycin, Amikacin, Tigecycline, Polymyxin B, Polymyxin E, Colistin, Minocycline, Doxycycline