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Isolation presents many obstacles in long-term care
Yet residents frequently carry MDROs
Preventing transmission of multidrug-resistant organisms (MDROs) presents particular challenges in the long-term care setting, where residents are encouraged to interact and single rooms are typically at a premium.
Moreover, residents may be colonized with more than one MDRO. One study of 117 residents found that 43% had at least one MDRO and 26% were colonized with more than one drug-resistant pathogen.1 These MDROs may include methicillin-resistant Staphylococcus aureus (MRSA), community-acquired (CA)-MRSA, vancomycin-resistant enterococci, and many other troublesome pathogens.
"There's the recent suggestion that Clostridium difficile itself might be considered an antibiotic resistant or quinolone resistant organism," noted Suzanne Bradley, MD, a health care epidemiologist at the University of Michigan Medical School in Ann Arbor. "So one of the challenges for people who work in nursing homes, where we have been told to cohort, is how do you cohort somebody who has MRSA and VRE, C. diff, or all of the above? How do you prioritize?"
Bradley recently discussed this difficult issue in Baltimore at the annual conference of the Society for Healthcare Epidemiology of America (SHEA) in Baltimore. Joining her in a "meet-the-consultants" session was Mary-Claire Roghmann, MD, MS, a health care epidemiologist in the VA Maryland Health Care System in Baltimore. "In acute care when I have someone who is colonized with a drug-resistant organism, I usually put them in a single room with contact precautions, which involves gloves for walking into the room and gowns if you are going to touch the patient and the environment," she said. "We don't let those patients out of their rooms except for medically necessary activities."
However, in applying infection prevention techniques in her system's affiliated long-term care setting, Roghmann encountered no shortage of obstacles. "In long-term care, I have a completely different situation," she says. "There are very few single rooms, and once a patient is put into a room I can't easily move them. That was a kind of shock to me. The residents are encouraged to interact with one another, eat in common areas, and share other activities."
Centers for Disease Control and Prevention guidelines recommend placing patients or residents with MDROs in a single room if possible, particularly if they have conditions that may facilitate transmission such as uncontained secretions or excretions.2 However, placing residents in private rooms may not be much of an option for many ICPs working in long-term care. "So this leads to the question of, 'What do you do with patients with multiple MDROs?'" Roghmann says. "Do you allow someone with MRSA and VRE [to room] with somebody who just has MRSA?"
Is it safe?
In general, patients with the same organisms should be placed together, but that may present logistic challenges as well, she conceded. The CDC recommends that if cohorting patients with the same MDRO is not possible, put the MRDO-colonized residents in rooms with those who are deemed at low risk for acquisition of MDROs, of having adverse outcomes from infection, and who are likely to have short lengths of stay.
"This is actually the first time we have had this in writing in terms of the guidelines," Roghmann said. "There was no question I needed to do this, but I had to ask myself whether it was safe or not. I think that the emphasis here is that you want them to be at low risk for acquisition, but also a low risk for developing infection if they happen to acquire the organism. That is one of the key factors that we have to keep in mind. For example, with MRSA, I would never put a [resident] with a large decubitus ulcer who is MRSA-negative with someone who is MRSA-positive. Skin breakdown is a risk factor for the development of an MRSA once you are colonized, and [also it is] a risk factor for acquiring an organism, so I wouldn't put those two patients together. "
In an encouraging finding that supports the CDC recommendation, Roghmann reported in a separate SHEA study that having an MRSA-positive roommate did not increase risk of acquisition of MRSA colonization in an extended care facility.3 "[The study showed] that room placement with a MRSA-positive [resident] was not a risk factor for acquiring MRSA if you were negative," she said. "No association whatsoever, and that was very reassuring to me."
Being bed-bound, having skin breakdown, and taking antibiotics all were associated with increase risk of MRSA acquisition in the study. Having a lower level of care (residential care vs. intermediate care) independently decreased the risk of MRSA acquisition, suggesting that the level of care should influence the intensity of infection control precautions. "The amount of contact that health care workers have with the residents could perhaps determine how much 'isolation' they get put on," she noted.
The CDC recommends that ICPs in long-term care 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 relatively healthy residents — those who are mainly independent — ICPs should follow standard precautions and make sure that gloves and gowns are used for contact with uncontrolled secretions, an approach long known as body substance isolation (BSI).
"This is a big recommendation for us," says Roghmann. "It is only a 'Category II.' It is not required, but it gives us something to start working with in making decisions about what we might do. Most of you are familiar with the rationale for BSI. It assumes you get the greatest amount of transmission form infectious material that is moist body substances [like] stool, urine, saliva. Whenever you are going to contact those body substances, gloves and gowns should be worn. The key issue about BSI, which has been incorporated into standard precautions, is that it is applied to all patients regardless of their known status."