Screening on admission for MRGNs

[Michael Wishart]

Hi all

Have a question about who is screening for what in regard to multiresistant gram negatives on admission. I mainly want to know about routine screening on admission to an acute facility on transfer from another facility, not specifically what you screen for in high risk units like ICU or dialysis, but all information is welcome!

Specifically, does anyone look for plasmid-mediated Amp-C betalactamase producers in routine rectal screens?

Thanks
Michael (and yes, I have moved jobs yet again!)

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3326 3523
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
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[John Ferguson]

Dear Michael

National recommendations on MRGN approaches including recommended lab workup will be ready later this year

In basic terms, I would suggest routine MRGN (and MRSA, VRE) screening for patients transferred from another facility, particularly if that facility is overseas or from another jurisdiction or state location

Most labs are using an ‘ESBL’ select agar (usually has cefpodoxime) which will pick up plasmid mediated ampC.
David Paterson wrote a useful review which includes a useful algorithm – abstract as follows.
(International Journal of Infectious Diseases (2007) 11, 191197)

Summary Plasmid-mediated class C b-lactamases are reported from Enterobacteriaceae with
increasing frequency. They likely originate from chromosomal AmpC of certain Gram-negative
bacterial species and subsequently are mobilized onto transmissible plasmids. There are reports
of unfavorable clinical outcomes in patients infected with these organisms and treated with
broad-spectrum cephalosporins. However, unlike class A extended-spectrum b-lactamases
(ESBLs), no screening and confirmatory tests have been uniformly established for strains that
produce class C b-lactamases. Reduced susceptibility to cefoxitin is a sensitive but not specific
indicator of class C b-lactamase production. Simple confirmatory tests including tests using
boronic acid compounds as specific class C b-lactamase inhibitors have recently been developed.
Their utilization will enable clinical microbiology laboratories to report those strains producing
plasmid-mediated class C b-lactamases as being resistant to all broad-spectrum cephalosporins,
thus allowing physicians to prescribe appropriate antimicrobial therapy.

John

Dr John Ferguson
Tel 61 2 4921 4444 | Fax 61 2 4921 4440 | Mob +61 428 885 573 | john.ferguson@hnehealth.nsw.gov.au | http://www.hicsiganz.org

[cid:image001.jpg@01CD5A93.9FAEAE50]

Hi all

Have a question about who is screening for what in regard to multiresistant gram negatives on admission. I mainly want to know about routine screening on admission to an acute facility on transfer from another facility, not specifically what you screen for in high risk units like ICU or dialysis, but all information is welcome!

Specifically, does anyone look for plasmidmediated Amp-C betalactamase producers in routine rectal screens?

Thanks
Michael (and yes, I have moved jobs yet again!)

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3326 3523
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

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[Anonymous]

Hi Michael.

We follow WA health dept. directives that require us to screen patients
that have been in a hospital outside WA in the last 12 months, for MRSA
and VRE.

In addition to this, we have at times been required to screen patients
transferred from ICU, Chemo, Renal in Perth for VRE when there has been
an outbreak in one of the major hospitals in Perth.

We routinely screen all nursing home patients for MRSA.

Regards,

Sandi Millington.

Available Mon, Tue and Thur.Acting Regional Infection Control CN.

Geraldton Hospital. 99562437.

Sandi.Millington@health.wa.gov.au

________________________________

Behalf Of Michael Wishart

Hi all

Have a question about who is screening for what in regard to
multiresistant gram negatives on admission. I mainly want to know about
routine screening on admission to an acute facility on transfer from
another facility, not specifically what you screen for in high risk
units like ICU or dialysis, but all information is welcome!

Specifically, does anyone look for plasmid-mediated Amp-C betalactamase
producers in routine rectal screens?

Thanks

Michael (and yes, I have moved jobs yet again!)

Michael Wishart

CNC Infection Control

Holy Spirit Northside Private Hospital

627 Rode Road, Chermside, Qld 4032

t: (07) 3326 3068 | f: (07) 3326 3523

e: Michael.Wishart@hsn.org.au

w:www.holyspiritnorthside.org.au

Please consider the environment before printing this email

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[Thomson, Rachel EA]

Hi Michael,

The Royal Hobart Hospital has recently implemented a protocol in
relation to MRGNs after pretty extensive work and consultation by our ID
and Micro team. We have updated our screening protocol in-line with
this. Simply put this is what we do

Screening in relation to MRGNs;

* Patients directly transferred from an overseas hospital

* Patients who have been admitted overnight to an overseas
hospital within the past 12 months

* Patients directly transferred from an intra-state or
inter-state intensive care unit

We only recommend isolation for those patients who are direct transfers

We classify our MRGNs as follows (and therefore look for the following);

* Acinetobacter spp. isolates intermediate/resistant to any
carbapenem

* Pseudomonas aeruginosa isolates resistant to at least 3 of the
following:

o Anti-pseudomonal carbapenem (meropenem, imipenem or doripenem)

o Gentamicin AND tobramycin

o Piperacillin/tazobactam AND ticarcillin/clavulanic acid

o Ciprofloxacin

o Ceftazidime AND cefepime/cefpirome

* Enterobacteriaceae isolates (excluding Salmonella and Shigella
spp.):

o intermediate/resistant to any Carbapenem

OR

o resistant to ampicillin/amoxycillin AND first generation
cephalosporins AND at least 3 of the following:

* Gentamicin AND tobramycin

* Ciprofloxacin OR norfloxacin

* Ceftriaxone OR ceftazidime

* Amoxycillin-clavulanate AND either ticarcillin-clavulanate or
piperacillin-tazobactam

* Any Gram-negative organism identified to have a transmissible
resistance mechanism such as:

o extended spectrum beta-lactamase (ESBL)

OR

o carbapenemase (including metallo-beta-lactamases (MBL) and
Klebsiella pneumoniae carbapenemases (KPC))

* Any other Gram-negative organism at the discretion of the
Medical Director of the Infection Prevention and Control Unit (or
delegate) – Hedging our bets here 🙂

Hope this is of assistance and interest. I would love to know what
other centres are doing!!

Cheers

Rachel

Rachel Thomson

Nurse Unit Manager

Infection Prevention & Control Unit

Royal Hobart Hospital

E: rachel.thomson@dhhs.tas.gov.au

________________________________

Behalf Of Michael Wishart

Hi all

Have a question about who is screening for what in regard to
multiresistant gram negatives on admission. I mainly want to know about
routine screening on admission to an acute facility on transfer from
another facility, not specifically what you screen for in high risk
units like ICU or dialysis, but all information is welcome!

Specifically, does anyone look for plasmid-mediated Amp-C betalactamase
producers in routine rectal screens?

Thanks

Michael (and yes, I have moved jobs yet again!)

Michael Wishart

CNC Infection Control

Holy Spirit Northside Private Hospital

627 Rode Road, Chermside, Qld 4032

t: (07) 3326 3068 | f: (07) 3326 3523

e: Michael.Wishart@hsn.org.au

w:www.holyspiritnorthside.org.au

Please consider the environment before printing this email

WARNING : This email contains information, which is CONFIDENTIAL, and
that maybe subject to LEGAL PRIVILEGE. This e-mail and any attachments
to it (the “Communication”) is confidential and is for the use only of
the intended recipient, and may not duplicated or used by any other
party without the express consent of the sender. The Communication may
contain copyright material of St Vincent’s Health & Aged Care(“SVHAC”),
or any of its related entities or of third parties. If you are not the
intended recipient of the Communication, please notify the sender
immediately by return e-mail, delete the Communication, and do not read,
copy, print, retransmit, store or act in reliance on the Communication.
Any views expressed in the Communication are those of the individual
sender only, unless expressly stated to be those of SVHAC. SVHAC does
not guarantee the integrity of the Communication, or that it is free
from errors, viruses or interference. Thank-you.

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