MDROs: An Equal Challenge for Healthcare Facilities and Communities

By Alicia Canales

Multidrug-resistant organisms (MDROs) causing healthcare- and community-associated infections are a growing concern still within the medical community. With little to no development in creating new antibiotics, hospitals are having to think outside of the box and take more precautions.

Some patients have Gram-negative bacteria that are resistant to every antibiotic at the Loyola University Medical System Infection Control Program, according to its medical director, Jorge Parada, MD, MPH, FACP, FIDSA. In some cases, he's had to give patients a combination therapy of multiple antibiotics.

"We sometimes tell ourselves, 'Well if we treat this infection, there's a high probability the patient will end up with kidney damage and perhaps even on dialysis.' So we might save the patient's life but make them a dialysis patient," Parada says. "That equation obviously falls in favor of the patient's life."

Pathogens that are most prevalent in hospital settings include methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella, Clostridium difficile and Acinebacter. Physicians have been reducing the number of antibiotics prescribed because increase usage results in the bacteria becoming resistant to the drugs, explains Lisa Waldowski, infection control specialist for the Joint Commission. When a patient has been exposed to several antibiotics, they are less likely to find one that will fight the infection.

"So if you truly get really sick and you have really limited now the choices that we're able to treat you with an antibiotic, that becomes a major problem," Waldowski says. "How are we going to save you? How are we going to treat you if we don't have any options?"

As C. difficile is becoming more difficult to treat with antibiotics, some doctors have turned to fecal transplants as a last resort, according to Waldowski. Stool is inserted through a tube and proceeds to eradicate the infection and help restore the gut flora.
"Even though it sounds kind of grungy, it's life saving for many people," Waldowski says.
She also mentioned there's discussion about hospitals implementing an antibiotic stewardship where they analyze which antibiotic is best for a given patient, and how long that patient should take it.

Physicians should also help educate patients on this concept as well, says Forest Arnold, DO, assistant professor at the University of Louisville. He says patients can be demanding about receiving antibiotics, even when they have a virus.

"Some physicians would rather just not deal with the conflict and find it easier to write the prescription than to have to explain all this," Arnold says. In order to contain the pathogens from spreading to other patients, hospitals should have a protocol already for patients with MDROs, Arnold adds.

Sometimes patients who already has a MRDO are transferred to another hospital. The staff member on the hospital receiving the patient needs to be aware of this to properly reserve a bed away from other patients, Arnold says. If a patient is admitted with such an organism, he or she should immediately go into contact isolation. Equipment in that room should be easily disposable or thoroughly cleaned afterward. The hospital's infection control department at the hospital should be notified as well, Arnold says. This way they can train that patient's family on proper protocols.

Physicians should also test patients for certain pathogens if they have reason to be suspicious, Waldowski says. If there has been prior issues within the hospital of locally, then they could culture the patient for MRSA, for example, when they admit him or her. Knowing the patient's history is also helpful when deciding whether to test patients, Waldowski adds.

One of the most important things for nurses and physicians to do is wash their hands before helping anyone else after attending to that infected patient, Arnold says. They would be carriers of the pathogen, but it wouldn't affect them much because they are healthy. However, it would transmit to and affect the other sick patient they helped.

"So it's bad enough they're already sick in the hospital with whatever they have, but to get this on top of it, you know that's just not serving the patient well at all," Arnold says. "In fact, it's wrong."

Some community-acquired MRSA can be resistant as well, Arnold said. While the patient may not need surgery, they would have a skin or soft tissue infection. Arnold said resistant MRSA used to be contained in the hospital more so, but it's possible staph has been transmitted to patients with short hospital stays.

Waldowski says different types of MRSA are found in the community than what is found in a healthcare facility. She mentioned the pathogen is in settings with a close proximity of people, such as a locker room or gym. Parada says many community-associated infections are found in nursing homes, especially those that continue antibiotic treatment. It is also picked up from environmental surfaces that are frequently touched.

A person can contract the bacteria, but be colonized and not have any symptoms. The symptoms, or clinical signs, could show if that person later had a surgery and was immunocompromised.

"Any healthy person can contract an MDRO infection, but persons who have more risk factors such as severe disease, recent surgery, and invasive medical devices are more prone to them," says Maria Whitaker, an infection preventionist at the Cortland Regional Medical Center in Cortland, N.Y.

Patients who are colonized also pose a risk because MRSA is spread through contact with surfaces, Waldowski says. A patient can be in the room, and the MRSA can spread throughout the room. While a nurse might not touch the patient, he or she can still pick up the bacteria from touching equipment or even curtains.

The community needs to be aware of the symptoms for pathogens, such as C. difficile and staph, Arnold says. It's hard to tell who has the infection already in public places, but a person can seek help sooner if they know they have the pathogen. Waldowski says good health practices, such as not sharing towels and keeping wounds covered, can help the community address MRSA and other bacteria.

"Hand hygiene doesn't have to stop when you leave a hospital setting," Waldowski says.
Because it's winter, hospitals are expecting cases of influenza, Waldowski says. The community should receive an influenza vaccination because it is designed to combat against three or four types of influenza viruses, according to Arnold.

Physicians misinterpreting a viral flu from a bacterial flu is a problem that arises during this season, Parada says.  A viral flu has the common symptoms, such as a fever or chills. Parada says one way to tell if it became bacterial is when the patient begins to cough up phlegm.

Parada encourages people to get the influenza vaccination, or any vaccination that's necessary. This prevents any chance of the patient receiving antibiotics that either he or she may not need, Parada says. Fewer antibiotics are preferred so that any pathogens that person carries will not become resistant to the drug.

"Every infection we prevent is one less opportunity to not use antibiotics," Parada says. "Never mind that, why would you want to get sick if you could avoid it?"