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CDC draft includes extra steps for multidrug-resistant organisms
Draft patient isolation guidelines by the Centers for Disease Control and Prevention include two tiers of infection control measures to thwart the rise of multidrug-resistant organisms. (MDROs). The baseline measures and intensified precautions from the sixth draft version of the document are summarized here:
Measures for all health care facilities
• Administrative measures: Designate MDRO prevention/control as an organizational priority with administrative support and resource allocation. Implement/ maintain systems to communicate information about reportable MDROs to administrative personnel and state/local health departments. Implement/maintain a multidisciplinary program to improve adherence to recommended practices for hand hygiene and infection control precautions. Include feedback. Implement/maintain communication systems to notify receiving clinicians when transferring known patients with MDROs.
• Education: Include MDRO education in the required curriculum of all health care worker professional training programs. Provide education and training on transmission risks and prevention of MDRO to patient care personnel during orientation and periodic educational updates. Include information on organizational experience, goals.
• Judicious antimicrobial use: Implement a system to educate prescribers to verify that prescribed antibiotics are active against the patient’s clinical isolates. In hospitals and long-term care facilities, ensure that a multi-disciplinary committee reviews antimicrobial utilization patterns and compares them with resistance patterns for purposes of minimizing selective pressure and providing appropriate antimicrobial coverage.
• Surveillance: Establish laboratory-based systems in hospital and commercial labs to detect and communicate evidence of MDROs in clinical isolates. Prepare, monitor facility-specific, high-risk unit-specific antimicrobial susceptibility reports. Provide physicians with summary reports. If microbiology services are outsourced, request local or regional aggregate susceptibility trends. Develop local, regional coalitions to share resistance data via health departments. Identify specific MDROs for systematic monitoring through review of susceptibility trends. Define frequency of MDROs that would trigger intensification of MDRO control. Store selected isolates for molecular typing.
• Infection control precautions: Observe standard precautions during all patient encounters on assumption any patient could be colonized with an MDRO. Prioritize known MDRO patients for single patient rooms or placement with like MDRO, or low-risk patient. For patients known to be colonized/infected with MDROs:
— Acute care settings: Implement contact precautions. If low likelihood of transmission, observe standard precautions, emphasizing hand hygiene.
— Long-term-care, ambulatory, home care: Implement contact precautions on a case-by-case basis determined by likelihood of transmission. Use hand hygiene, gloves when contact precautions not indicated.
• Environmental measures: Use routine cleaning, sterilization, and disinfection procedures for maintaining patient care areas, devices, and medical equipment.
Additional measures for ongoing MDRO transmission
• Administrative measures: Intensify MDRO control when ongoing transmission, prevalence exceeds institutional goals, or new MDRO appears. In the absence of dedicated infection control staff, consult with infection control professionals and health care epidemiologists with expertise and knowledge of the epidemiology of MDROs for assessment, design, implementation, evaluation of control measures. Evaluate system factors, including staffing levels, for role in MDRO transmission. Provide feedback to clinicians on facility trends in resistance, adherence monitoring, and system failures. When increased incidence of a targeted MDRO is observed, implement intensive monitoring of selected indicators.
• Education: Implement educational programs facility-wide and/or in high-risk units targeted for intensified MDRO control interventions. Include relevant information on MDRO trends, system failures, action plans and their outcomes.
• Judicious antimicrobial use: Restrict use of antimicrobial agents that are associated with increased prevalence of target MDRO (e.g., vancomycin.)
• Surveillance: Calculate and analyze prevalence and incidence rates of target MDROs. Increase frequency of compiling and monitoring antimicrobial susceptibility summary reports. Develop and implement protocols to obtain active surveillance cultures in at-risk populations as defined locally.
— Obtain culture at time of admission.
— Conduct unit point prevalence studies.
— Repeat cultures at defined intervals until transmission has ceased.
— Obtain surveillance cultures from roommates and other patients with significant exposure to known MDRO-positive patients.
Implement laboratory protocols for storing isolates of selected MDROs for molecular typing; perform typing if needed. Obtain cultures from health care workers for target MDROs only if epidemiologic evidence implicates workers as a source of transmission.
• Infection control precautions: Implement contact precautions for all patients known to be colonized/infected with target MDRO. As part of an active surveillance program, implement routine use of contact precautions (e.g., gloves, gowns) for room entry and contact with patients and their environment pending negative surveillance culture results. Implement interim policies for patient placement and staffing as needed to prevent transmission (e.g., cohorting patients/staff; unit or facility closure)
• Environmental measures: Implement patient- dedicated use of noncritical equipment. Re-prioritize assignment of cleaning personnel; dedicate consistent individuals to targeted patient care areas to enhance cleaning and disinfection. Implement procedures that ensure consistent attention is given to "high-touch" surfaces in patient care areas. Obtain cultures from environmental sources (e.g., surfaces, shared equipment) only when epidemiologically implicated in transmission. Vacate units for environmental assessment and intensive cleaning when previous efforts to control environmental transmission have failed.