Costquantity of empiric antimicrobial administered in a specified period.

Policies and Procedures on Infection Control Ministry of Health Malaysia 174 Examples from Harbath et al 2001 on correlation between antimicrobial use and resistance Figure 1. A, Third-generation cephalosporin susceptibility among Enterobacteriaceae solid line and use in defined daily doses DDDs; dotted line. Examples from Lepper et al, 2002 Policies and Procedures on Infection Control Ministry of Health Malaysia 175

13.1.1 Introduction

Multi-resistant organisms are bacteria that have developed resistance to more than 2 different groups of any used antibiotics. Development of multi-drug resistance has been associated with inappropriate and over use of antibiotics Resistant organisms of significance in healthcare settings include Pseudomonas aeruginosa, Acinetobacter and Extended-spectrum beta lactamase ESBL-producing bacteria which are most commonly produced among Escherichia coli E. coli, Klebsiella and Proteus.

13.1.1.1 ESBLs and ESBL Infection

• ESBL are bacterial enzymes that have conferred resistance to second and third generation cephalosporins antibiotics. ESBLs are the cause of multi- drug resistant gram negative bacteria around the world. •· Treatment of choice includes carbapenems and tigecycline

13.1.1.2 Pseudomonas aeruginosa

• Pseudomonas aeruginosa is a gram-negative bacterium normally found in soil and water. It rarely affects healthy people, but can cause serious illness in immunocompromised people HIV or cancer patients. • In healthcare settings it contaminates wet reservoirs e.g. indwelling catheters and can cause serious bloodstream infections.

13.1.1.3 Acinetobacter

• Acinetobacter is a gram-negative bacterium, normally lives in soil and water and can sometimes be found on the skin, posing no risk to healthy people. •· It can live in the environment for several days. There are several species and a few can cause infections in people who are already unwell.

13.1.2 Transmission

• The transmission of multi-resistant organisms in hospital and community is by person to person spread either directly via staff, patient or visitor unwashed hands that have been contaminated by contact with colonised or infected patient or indirectly from contaminated equipment and surfaces. • ESBLs can also be transmitted via the faecal oral route.

13.1 Multi-Resistant Organism 13.

SPECIFIC ORGANISM RELATED INFORMATION