Infection
Prevention and
Control Week 2016
Day 4 - Multi Drug
Resistant Organisms ESBL & MDRKP
Multidrug-Resistant Organisms
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Multidrug-resistant organisms (MDRO) are microorganisms predominantly
bacteria, which are resistant to one or more groups of antibiotics

People may be colonised with an MDRO and not feel any ill effects. However
occasionally these organisms do cause infections. Treating these microorganisms
can be difficult due to their antimicrobial resistance

In some cases, the microorganisms have become so resistant that none or maybe
only one group of antibiotic are still effective against the infection

There are different mechanisms that bacteria use in order to develop resistance to
antibiotics. Bacteria can use both genetic material and also enzymes to develop
resistance to antibiotics, such as ESBL producing bacteria.
Common multidrug-resistant organisms (MDRO) that you may have heard of in the media or in a
healthcare setting
ESBL – Extended Spectrum Beta Lactamase


ESBLs are enzymes that enable resistance to extended-spectrum antibiotics (third
generation) cephalosporins (e.g., ceftazidime, cefotaxime, and ceftriaxone) and
monobactams (e.g., aztreonam) but do not affect cephamycins (e.g. cefoxitin and cefotetan)
or carbapenems (e.g., meropenem or imipenem).
K. pneumoniae, K. oxytoca, and E. coli bacteria can produce ESBLs leading to resistance to
antibiotics.

Other Enterobacteriaceae (gut bacteria), such as Salmonella species and Proteus mirabilis,
and Pseudomonas aeruginosa can also produce ESBLs.

Bacteria that produce ESBL’s tend to also develop further multidrug resistance to antibiotics
and the resistance can often include different bacteria species.

Multiple Multidrug resistant organisms can be a challenge to treat.
Multidrug-Resistant Klebsiella Pneumonia (MDRKP)

Klebsiella pneumonia (KP) is just one of many different types of bacteria that live in the
bowel.

KP live harmlessly in the bowel and do not cause infection, however KP can develop
resistance to antibiotics, this is then called MDR-KP

However, sometimes both KP and MDR‐KP can cause infection, for example in a vulnerable
patient who might be in the intensive care unit or receiving chemotherapy.

Antibiotics are needed to treat infection caused by MDR‐KP. If a patient is prone to
infection and the infection is caused by MDR‐KP, it can be more difficult to treat,
because many of the commonly used antimicrobials will not work.
Although MDR‐KP live in the bowel they do not cause diarrhoea. However, if a person
has diarrhoea for some other reason they can then enter the environment more readily.
In line with standard precautions, all staff must clean their hands before and after any
contact with every patient, regardless of whether or not the patient has MDR‐KP and as
per the ‘5 Moments of Hand Hygiene’.
HPSC 2014


How do bacteria become resistant!
CDC 2015
How are MDRKP and ESBL producing organisms detected?


The organism known as ‘Klebsiella Pneumoniae’ can normally be found in the mouth, skin,
and intestinal tract, where it does not cause disease and is part of the normal flora.
If Klebsiella pneumoniae enters a sterile part of the body it may result in an infection.
Bacterial infections from Klebsiella Pneumoniae can lead to pneumonia, bloodstream
infections, wound infections, urinary tract infections, and meningitis.

The organisms are detected from a clinical sample that has been sent for culture and
sensitivity in the microbiology lab.


The organisms are then tested for their sensitivity to different types of antibiotic.

Klebsiella Pneumoniae can develop Antibiotic Resistance to one or more groups of
antibiotics leading to a MDRKP and the bacteria may also produce the ESBL enzyme. The
patient would then have an ESBL producing MDRKP.

Antibiotics are needed to treat infection caused by MDR‐KP. If a patient is prone to
infection and the infection is caused by MDR‐KP, it can be more difficult to treat,
because many of the commonly used antibiotics will not work.
Although MDR‐KP live in the bowel they do not cause diarrhoea. However, if a person
has diarrhoea for some other reason they can then be spread more easily.
All staff must clean their hands before and after any contact with every patient,
regardless of whether or not the patient has MDR‐KP and as per the ‘5 Moments of
Hand Hygiene’.
HPSC 2014
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
The organisms undergo further testing to detect for the enzyme present in an ESBL
producing organism.
Infection Prevention and Control Precautions
In order to protect all healthcare workers and patients - Standard Precautions should be
used for all patients regardless of their history or infectious status
• Patients known to be colonised (have a history) or have an active infection with an MDRO should
be admitted to a single room with en-suite toilet and managed with contact precautions
• An en-suite room is preferable, but if one is not available, a commode should be dedicated for each
patient’s individual use
• If limited isolation facilities are available a local risk assessment should be undertaken. This can be
discussed with the Infection Prevention and Control Team.
• Careful adherence to Hand hygiene as per the ‘5 moments of hand hygiene’
• In the acute hospital setting, healthcare workers should use disposable long‐sleeved gowns and
disposable gloves for close physical contact with the patient.
• Facemasks and eye protection should be worn in accordance with standard precautions when
performing aerosol generating procedures
• The door to the patient’s room should be kept closed to minimise spread to adjacent areas and the
patient should have their own dedicated equipment (BP cuffs, thermometers etc.). All medical
equipment requires decontamination prior to removed from the room.
• The appropriate signage should be placed on the outside of the door to alert healthcare workers of
the need to apply contact precautions
• Increased and enhanced cleaning with special attention to frequently-touched surfaces, such as bed
rails, bed side chairs and door handles, is required
A terminal clean of the room is required after patient discharge.
CDC 2015
The HPSC website also has a variety of patient advice leaflets available for download, see link below:
http://www.hpsc.ie/Publications/InformationLeafletsfortheGeneralPublic/
----------------------------------------------------------------------------------------------------------------------------If you would like further information on Multidrug Resistance please follow the links below:
Healthcare A2Z - https://healthcarea2z.org/monthlyupdate/special-update.html
Centers for Disease Control and Prevention - http://www.cdc.gov/hicpac/mdro/mdro_4.html
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http://www.cdc.gov/drugresistance/biggest_threats.html
HPSC - http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/
https://www.hpsc.ie/Publications/InformationLeafletsfortheGeneralPublic/File,14904,en.pdf
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