Management of Multidrug-Resistant Organisms (MDROs) and Outbreak Situations

Recommendations

1.  Administrative Measures

Make MDRO prevention and control an organizational patient safety priority (Strong Recommendation)

Provide administrative support, and both financial and human resources, to prevent and control MDRO transmission within the healthcare organization. (Strong Recommendation)

Implement a multidisciplinary process to monitor and improve healthcare personnel (HCP) adherence to recommended practices for Standard and Contact Precautions. (Strong Recommendation)

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. (Strong Recommendation)

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.

(Strong Recommendation)

2. Education and Training of Healthcare Personnel

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. (Strong Recommendation)

3. Judicious Use of Antimicrobial Agents

In hospitals and long-term care facilities, 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. (Strong Recommendation)

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. (Strong Recommendation)

Provide clinicians with antimicrobial susceptibility reports and analysis of current trends, updated at least annually, to guide antimicrobial prescribing practices. (Strong Recommendation)

In settings that administer antimicrobial agents but have limited electronic communication system infrastructures to implement physician prompts, implement a process for appropriate review of prescribed antimicrobials. Prepare and distribute reports to prescribers that summarize findings and provide suggestions for improving antimicrobial use. (Good Practice Statement)

4. Surveillance

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- MDROs. (Strong Recommendation)

In all healthcare organizations, establish systems to ensure that clinical microbiology laboratories (in-house and out-sourced) promptly notify infection control staff when a novel resistance pattern for that facility is detected. (Strong Recommendation)

In hospitals and long-term care facilities, 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. (Strong Recommendation)

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. (Strong Recommendation)

Specify isolate origin (i.e., location and clinical service) in MDRO monitoring protocols in hospitals and other large multi-unit facilities with high-risk patients. (Strong Recommendation)

Establish a baseline (e.g., incidence) for targeted MDRO isolates by reviewing results of clinical cultures; if more timely or localized information is needed, perform baseline point prevalence studies of colonization in high-risk units. When possible, distinguish colonization from infection in analysis of these data. (Strong Recommendation)

5. Infection Control Precautions to Prevent Transmission of MDROs

Follow Standard Precautions during all patient encounters in all settings in which healthcare is delivered. (Strong Recommendation)

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) (Strong Recommendation)

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). (Strong Recommendation)

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. (Good Practice Statement)

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. (Good Practice Statement)

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. (Good Practice Statement)

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. (Good Practice Statement)

When single-patient rooms are available, assign priority for these rooms to patients with known or suspected MDRO colonization or infection. Give highest priority to those patients who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions. (Strong Recommendation)

When single-patient rooms are not available, cohort patients with the same MDRO in the same room or patient-care area. (Strong Recommendation)

When cohorting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection and are likely to have short lengths of stay. (Good Practice Statement)

6.  Environmental Measures

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). (Strong Recommendation)

Dedicate noncritical medical items to use on individual patients known to be infected or colonized with MDROs. (Strong Recommendation)

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. (Strong Recommendation)