VI. Prevention of Transmission of Multidrug Resistant Organisms

The CDC/HICPAC system for categorizing recommendations is as follows:

Category IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC Required for implementation, as mandated by federal and/or state regulation or standard.

Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

No recommendation Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

 

V.A. General recommendations for all healthcare settings independent of the prevalence of multidrug resistant organism (MDRO) infections or the population served. (See Table 3, Tier 1.)

V.A.1. Administrative Measures

V.A.1.a. Make MDRO prevention and control an organizational patient safety priority.^{3, 146, 151, 154, 182, 185, 194, 205, 208, 210, 242, 327, 328} Category IB

V.A.1.b. Provide administrative support, and both fiscal and human resources, to prevent and control MDRO transmission within the healthcare organization. ^{3, 9, 146, 152, 182-184, 208, 328, 329} Category IB

V.A.1.c. In healthcare facilities without expertise for analyzing epidemiologic data, recognizing MDRO problems, or devising effective control strategies (e.g., small or rural hospitals, rehabilitation centers, long-term care facilities [LTCFs], freestanding ambulatory centers), identify experts who can provide consultation as needed.^{151, 188} Category II

V.A.1.d. Implement systems to communicate information about reportable MDROs [e.g., VRSA, VISA, MRSA, Penicillin resistant S. pneumoniae (PRSP)] to administrative personnel and as required by state and local health authorities ([This link is no longer active: www.cdc.gov/epo/dphsi/nndsshis.htm. Information may be available on National Notifiable Diseases Surveillance System (NNDSS) website accessed May 4, 2016]).Refer to websites for updated requirements of local and state health departments. Category II/IC

V.A.1.e. Implement a multidisciplinary process to monitor and improve healthcare personnel (HCP) adherence to recommended practices for Standard and Contact Precautions^{3, 105, 182, 184, 189, 242, 273, 312, 330} Category IB

V.A.1.f. Implement systems to designate patients known to be colonized or infected with a targeted MDRO and to notify receiving healthcare facilities and personnel prior to transfer of such patients within or between facilities.^{87, 151} Category IB

V.A.1.g. Support participation of the facility or healthcare system in local, regional, and national coalitions to combat emerging or growing MDRO problems.^{41, 146, 151, 167, 188, 206, 207, 211, 331} Category IB

V.A.1.h. Provide updated feedback at least annually to healthcare providers and administrators on facility and patient-care-unit trends in MDRO infections. Include information on changes in prevalence or incidence of infection, results of assessments for system failures, and action plans to improve adherence to and effectiveness of recommended infection control practices to prevent MDRO transmission.^{152, 154, 159, 184, 204, 205, 242, 312, 332} Category IB

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V.A.2. Education and Training of Healthcare Personnel

V.A.2.a. Provide education and training on risks and prevention of MDRO transmission during orientation and periodic educational updates for healthcare personnel; include information on organizational experience with MDROs and prevention strategies.^{38, 152, 154, 173, 176, 189, 190, 203, 204, 217, 242, 330, 333, 334} Category IB

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V.A.3. Judicious Use of Antimicrobial Agents ~ (i.e., systems to promote optimal treatment of infections and appropriate antimicrobial use).

V.A.3.a. In hospitals and LTCFs, ensure that a multidisciplinary process is in place to review antimicrobial utilization, local susceptibility patterns (antibiograms), and antimicrobial agents included in the formulary to foster appropriate antimicrobial use.^{209, 212, 214, 215, 217, 242, 254, 334-339} Category IB

V.A.3.b. Implement systems (e.g., computerized physician order entry, comment in microbiology susceptibility report, notification from a clinical pharmacist or unit director) to prompt clinicians to use the appropriate antimicrobial agent and regimen for the given clinical situation.^{156, 157, 161, 166, 174, 175, 212, 214, 218, 254, 334, 335, 337, 340-346} Category IB

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V.A.4. Surveillance

V.A.4.a. In microbiology laboratories, use standardized laboratory methods and follow published guidance for determining antimicrobial susceptibility of targeted (e.g., MRSA, VRE, MDR-ESBLs) and emerging (e.g., VRSA, MDR-Acinetobacter baumannii) MDROs.^{8, 154, 177, 190, 193, 209, 254, 347, 350-353} Category IB

V.A.4.b. In all healthcare organizations, establish systems to ensure that clinical microbiology laboratories (in-house and out-sourced) promptly notify infection control staff or a medical director/ designee when a novel resistance pattern for that facility is detected.^{9, 22, 154, 162, 169} Category IB

V.A.4.c. In hospitals and LTCFs, develop and implement laboratory protocols for storing isolates of selected MDROs for molecular typing when needed to confirm transmission or delineate the epidemiology of the MDRO within the healthcare setting.^{7, 8, 38, 140, 153, 154, 187, 190, 208, 217, 354, 355} Category IB

V.A.4.d. Prepare facility-specific antimicrobial susceptibility reports as recommended by the Clinical and Laboratory Standards Institute (CLSI) ([This link is no longer active: www.phppo.cdc.gov/dls/master/default.aspx.]); monitor these reports for evidence of changing resistance patterns that may indicate the emergence or transmission of MDROs.^{347, 351, 356, 357} Category IB/IC

V.A.4.e. Monitor trends in the incidence of target MDROs in the facility over time using appropriate statistical methods to determine whether MDRO rates are decreasing and whether additional interventions are needed.^{152, 154, 183, 193, 205, 209, 217, 242, 300, 325, 326, 364, 365} Category IA

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V.A.5. Infection Control Precautions to Prevent Transmission of MDROs

V.A.5.a. Follow Standard Precautions during all patient encounters in all settings in which healthcare is delivered.^{119, 164, 255, 315, 316} Category IB

V.A.5.b. Use masks according to Standard Precautions when performing splash-generating procedures (e.g., wound irrigation, oral suctioning, intubation); when caring for patients with open tracheostomies and the potential for projectile secretions; and in circumstances where there is evidence of transmission from heavily colonized sources (e.g., burn wounds). Masks are not otherwise recommended for prevention of MDRO transmission from patients to healthcare personnel during routine care (e.g., upon room entry).^{8, 22, 151, 152, 154, 189, 190, 193, 208, 240, 366} Category IB

V.A.5.c. Use of Contact Precautions

V.A.5.c.i. In acute-care hospitals

Implement Contact Precautions routinely for all patients infected with target MDROs and for patients that have been previously identified as being colonized with target MDROs (e.g., patients transferred from other units or facilities who are known to be colonized).^{11, 38, 68, 114, 151, 183, 188, 204, 217, 242, 304} Category IB

V.A.5.c.ii. In LTCFs

1. * Consider the individual patient’s clinical situation and prevalence or incidence of MDRO in the facility when deciding whether to implement or modify Contact Precautions in addition to Standard Precautions for a patient infected or colonized with a target MDRO. Category II
2. * For relatively healthy residents (e.g., mainly independent) follow Standard Precautions, making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes/bags.^{78-80, 85, 151, 367, 368} Category II
3. * For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living, ventilator-dependent) and for those residents whose infected secretions or drainage cannot be contained, use Contact Precautions in addition to Standard Precautions.^{316, 369, 370} Category II
4. * For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on their risk to other patients and on the ability of the colonized or infected patients to observe proper hand hygiene and other recommended precautions to contain secretions and excretions.^{151, 163, 371} Category II

V.A.5.d. In ambulatory settings

Use Standard Precautions for patients known to be infected or colonized with target MDROs, making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes and bags. Category II

V.A.5.e. In home care settings

1. * Follow Standard Precautions making sure to use gowns and gloves for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes and bags. Category II
2. * Limit the amount of reusable patient-care equipment that is brought into the home of patients infected or colonized with MDROs. When possible, leave patient-care equipment in the home until the patient is discharged from home care services. Category II
3. * If noncritical patient-care equipment (e.g., stethoscopes) cannot remain in the home, clean and disinfect items before removing them from the home, using a low to intermediate level disinfectant, or place reusable items in a plastic bag for transport to another site for subsequent cleaning and disinfection. Category II

V.A.5.f. * In ambulatory or home care settings

No recommendation is made for routine use of gloves, gowns, or both to prevent MDRO transmission in ambulatory or home care settings. Unresolved issue

V.A.5.g. * In hemodialysis units

Follow the “Recommendations to Prevent Transmission of Infections in Chronic Hemodialysis Patients”³⁷² ([This link is no longer active: www.cms.hhs.gov/home/regsguidance.asp]). Category IC

V.A.5.h. * Discontinuation of Contact Precautions.

No recommendation can be made regarding when to discontinue Contact Precautions. Unresolved issue (See Background for discussion of options.)

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V.A.6. Environmental Measures

V.A.6.a. Clean and disinfect surfaces and equipment that may be contaminated with pathogens, including those that are in close proximity to the patient (e.g., bed rails, over bed tables) and frequently-touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding toilets in patients’ rooms) on a more frequent schedule compared to that for minimal touch surfaces (e.g., horizontal surfaces in waiting rooms).^{111, 297, 373} Category IB

V.A.6.b. Dedicate noncritical medical items to use on individual patients known to be infected or colonized with MDROs.^{38, 217, 323, 374, 375} Category IB

V.A.6.c. Prioritize room cleaning of patients on Contact Precautions. Focus on cleaning and disinfecting frequently touched surfaces (e.g., bedrails, bedside commodes, bathroom fixtures in the patient’s room, doorknobs) and equipment in the immediate vicinity of the patient.^{109, 110, 114-117, 297, 301, 373, 376, 377} Category IB

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V.B. Intensified interventions to prevent MDRO transmission (See Table 3, Tier 2.)

The interventions presented below have been utilized in various combinations to reduce transmission of MDROs in healthcare facilities. Neither the effectiveness of individual components nor that of specific combinations of control measures has been assessed in controlled trials. Nevertheless, various combinations of control elements selected under the guidance of knowledgeable content experts have repeatedly reduced MDRO transmission rates in a variety of healthcare settings.

V.B.1. Indications and Approach

V.B.1.a. Indications for intensified MDRO control efforts (VII.B.1.a.i and VII.B.1.a.ii) should result in selection and implementation of one or more of the interventions described in VII.B.2 to VII.B.8 below. Individualize the selection of control measures according to local considerations.^{8, 11, 38, 68, 114, 152-154, 183-185, 189, 190, 193, 194, 209, 217, 242, 312, 364, 365} Category IB

V.B.1.b. Continue to monitor the incidence of target MDRO infection and colonization after additional interventions are implemented. If rates do not decrease, implement more interventions as needed to reduce MDRO transmission.^{11, 38, 68, 92, 152, 175, 184, 365} Category IB

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V.B.2. Administrative Measures

V.B.2.a. Identify persons with experience in infection control and the epidemiology of MDRO, either in house or through outside consultation, for assessment of the local MDRO problem and for the design, implementation, and evaluation of appropriate control measures.^{3, 68, 146, 151-154, 167, 184, 190, 193, 242, 328, 377} Category IB

V.B.2.b. Provide necessary leadership, funding, and day-to-day oversight to implement interventions selected. Involve the governing body and leadership of the healthcare facility or system that have organizational responsibility for this and other infection control efforts.^{8, 38, 152, 154, 184, 189, 190, 208} Category IB

V.B.2.c. Evaluate healthcare system factors for their role in creating or perpetuating transmission of MDROs, including: staffing levels, education and training, availability of consumable and durable resources, communication processes, policies and procedures, and adherence to recommended infection control measures (e.g., hand hygiene and Standard or Contact Precautions). Develop, implement, and monitor action plans to correct system failures.^{3, 8, 38, 152, 154, 172, 173, 175, 188, 196, 198, 199, 208, 217, 280, 323, 379, 380} Category IB

V.B.2.d. During the process, update healthcare providers and administrators on the progress and effectiveness of the intensified interventions. Include information on changes in prevalence, rates of infection and colonization; results of assessments and corrective actions for system failures; degrees of adherence to recommended practices; and action plans to improve adherence to recommended infection control practices to prevent MDRO transmission.^{152, 154, 159, 184, 204, 205, 312, 332, 381} Category IB

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V.B.3. Educational Interventions

Intensify the frequency of MDRO educational programs for healthcare personnel, especially those who work in areas in which MDRO rates are not decreasing. Provide individual or unit-specific feedback when available.^{3, 38, 152, 154, 159, 170, 182, 183, 189, 190, 193, 194, 204, 205, 209, 215, 218, 312} Category IB

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V.B.4. Judicious Use of Antimicrobial Agents

Review the role of antimicrobial use in perpetuating the MDRO problem targeted for intensified intervention. Control and improve antimicrobial use as indicated. Antimicrobial agents that may be targeted include vancomycin, third-generation cephalosporins, and anti-anaerobic agents for VRE (217); third-generation cephalosporins for ESBLs; ^{212, 214, 215} and quinolones and carbapenems.^{80, 156, 166, 174, 175, 209, 218, 242, 254, 329, 334, 335, 337, 341} Category IB

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V.B.5. Surveillance

V.B.5.a. Calculate and analyze prevalence and incidence rates of targeted MDRO infection and colonization in populations at risk; when possible, distinguish colonization from infection^{152, 153, 183, 184, 189, 190, 193, 205, 215, 242, 365} Category IB

V.B.5.b. Develop and implement protocols to obtain active surveillance cultures (ASC) for targeted MDROs from patients in populations at risk (e.g., patients in intensive care, burn, bone marrow/stem cell transplant, and oncology units; patients transferred from facilities known to have high MDRO prevalence rates; roommates of colonized or infected persons; and patients known to have been previously infected or colonized with an MDRO).^{8, 38, 68, 114, 151-154, 167, 168, 183, 184, 187-190, 192, 193, 217, 242} Category IB

V.B.5.c. Conduct culture surveys to assess the efficacy of the enhanced MDRO control interventions.

V.B.5.d. Obtain cultures of healthcare personnel for target MDRO when there is epidemiologic evidence implicating the healthcare staff member as a source of ongoing transmission.^{153, 365} Category IB

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V.B.6. Enhanced Infection Control Precautions

V.B.6.a. * Use of Contact Precautions

V.B.6.b. When ASC are obtained as part of an intensified MDRO control program, implement Contact Precautions until the surveillance culture is reported negative for the target MDRO.^{8, 30, 153, 389, 390} Category IB

V.B.6.c. No recommendation is made regarding universal use of gloves, gowns, or both in high-risk units in acute-care hospitals.^{153, 273, 312, 320, 391} Unresolved issue

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V.B.7. Patient Admission and Placement

V.B.7. Implement policies for patient admission and placement as needed to prevent transmission of a problem MDRO.^{183, 184, 189, 193, 242, 339, 392} Category IB

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V.B.8. Enhanced Environmental Measures

V.B.8.a. Implement patient-dedicated or single-use disposable noncritical equipment (e.g., blood pressure cuff, stethoscope) and instruments and devices.^{38, 104, 151, 156, 159, 163, 181, 217, 323, 329, 367, 389, 390, 394} Category IB

V.B.8.b. Intensify and reinforce training of environmental staff who work in areas targeted for intensified MDRO control and monitor adherence to environmental cleaning policies. Some facilities may choose to assign dedicated staff to targeted patient care areas to enhance consistency of proper environmental cleaning and disinfection services.^{38, 154, 159, 165, 172, 173, 175, 178-181, 193, 205, 208, 217, 279, 301, 327, 339, 397} Category IB

V.B.8.c. Monitor (i.e., supervise and inspect) cleaning performance to ensure consistent cleaning and disinfection of surfaces in close proximity to the patient and those likely to be touched by the patient and HCP (e.g., bedrails, carts, bedside commodes, doorknobs, faucet handles).^{8, 38, 109, 111, 154, 169, 180, 208, 217, 301, 333, 398} Category IB

V.B.8.d. Obtain environmental cultures (e.g., surfaces, shared medical equipment) when there is epidemiologic evidence that an environmental source is associated with ongoing transmission of the targeted MDRO.^399-402 Category IB

V.B.8.e. Vacate units for environmental assessment and intensive cleaning when previous efforts to eliminate environmental reservoirs have failed.^{175, 205, 279, 339, 403} Category II

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V.B.9. Decolonization

V.B.9.a. Consult with physicians with expertise in infectious diseases and/or healthcare epidemiology on a case-by-case basis regarding the appropriate use of decolonization therapy for patients or staff during limited periods of time, as a component of an intensified MRSA control program.^{152, 168, 170, 172, 183, 194, 304} Category II

V.B.9.b. When decolonization for MRSA is used, perform susceptibility testing for the decolonizing agent against the target organism in the individual being treated or the MDRO strain that is epidemiologically implicated in transmission. Monitor susceptibility to detect emergence of resistance to the decolonizing agent. Consult with a microbiologist for appropriate testing for mupirocin resistance, since standards have not been established.^{289, 290, 304, 308} Category IB

V.B.9.c. No recommendation can be made for decolonizing patients with VRE or MDR-GNB. Regimens and efficacy of decolonization protocols for VRE and MDR-GNB have not been established.^{284, 286, 288, 307, 387, 405} Unresolved issue

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