Lessons Learned: Mitigating the Challenges of Urgently Threatening Antibiotic Resistant Pathogens in a Large Academic Medical Center

Abstract

<h3>Background</h3> Care of urgently threatening antibiotic resistant pathogens such as Vancomycin Intermediate/Resistant Staphylococcus aureus (VISA/VRSA) and Carbapenem-resistant Enterobacteriaceae (CRE) poses unique challenged in managing care of critically ill patients in intensive care units (ICUs). Care of the patient, care of the environment, and compliance of infection control policies are priorities to uphold safety of the patient and the healthcare worker. <h3>Methods</h3> The Infection Prevention Program was notified from the laboratory of VISA positive and CRE positive patients residing in the hospital's Medical-Respiratory ICU. Patient's cases were individually reviewed for culture results, comorbidity, presence of invasive devices, laboratory values, and intact skin. Epidemiologic risk assessment was completed and the VISA/VRSA Policy was initiated in both instances. The policy includes recommendations consistent with Centers for Disease Control and Prevention's "Multi-drug resistant organisms (MDRO) Management Guidelines." (CDC, 2015). Several escalated interventions were determined to be prudent as a result of the epidemiologic risk assessment: addition of a 24-hour door monitor outside the patients' rooms, wearing sterile gown and trauma boots during wound care for the CRE-positive patient, and restriction of movement within the facility. <h3>Results</h3> Initial activation of the VISA/VRSA Policy was met with resistance from bedside staff secondary to staffing constraints, fear of transmission, confusion of risk involved, and misunderstanding of patient movement restriction. Resistance was lessened through timely intervention from Infection Preventionists, who formulated action plan as follows: consult help from hospital administration and allocate additional staff from the supplemental department, create and disperse education video on contact precautions, and develop schematics to guide actions when patient must leave floor for diagnostic exams. <h3>Conclusions</h3> Safe management of patients with high-risk MDRO's requires collaboration between Epidemiology, nursing, physicians, laboratory, environmental services, bed management, radiology, supplemental staffing and hospital leadership.