ISOLATION PRECAUTIONS AND MANAGEMENT OF MULTIDRUGRESISTANT ORGANISMS (MDROS) IN LONG-TERM CARE FACILITIES Evelyn Cook, RN, CIC Associate Director OBJECTIVES Review Isolation Precautions Review how Multi-drug Resistant Organisms (MDROs) emerge Review the management of MDROs 2007 Guideline for Isolation

Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, hD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices dvisory Committee KEY CONCEPTS Risk of transmission of infectious agents occurs in all settings Infections are transmitted from patient-to-patient via HCPs

hands or medical equipment/devices Isolation precautions are only part of a comprehensive IP program Unidentified patients who are colonized or infected may represent risk to other patients FUNDAMENTAL ELEMENTS Administrative support Adequate Infection Prevention staffing Good communication with clinical microbiology lab and environmental services

A comprehensive educational program for HCPs, patients, and visitors Infrastructure support for surveillance, outbreak tracking, and data management STANDARD PRECAUTIONS Implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel

HAND HYGIENE After touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts. HAND HYGIENE

HAND HYGIENE SOAP + WATER OR Alcohol based hand rub SOAP AND WATER When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water

SOAP AND WATER Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores. HOW TO WASH HANDS Wet hands with water Apply amount of product recommended by manufacturer Rub hands together vigorously at least 15 seconds,

covering ALL surfaces of the hands and fingers Rinse hands Dry with disposable towel Use towel to turn off faucet (and open door) ALCOHOL BASED HAND RUB If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations (listed next). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described. Before direct contact with patient Before donning sterile gloves

Before inserting ANY invasive device (indwelling urinary catheters for example) After contact with intact skin After contact with body fluids, excretions, mucous membranes etc., if not visible soiled If moving from contaminated body site to clean body site After contact with inanimate objects (environment, medical equipment) After removing gloves HOW TO USE AN ALCOHOL BASED HAND RUB Apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry

Follow the manufacturers recommendations regarding the volume of product to use. OTHER ASPECTS OF HAND HYGIENE Do not wear artificial fingernails or extenders when having direct contact with patients at high risk Keep natural nails tips less than 1/4-inch long Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash

gloves between uses with different patients Change gloves during patient care if moving from a contaminated body site to a clean body site STANDARD PRECAUTIONS Component Recommendation Personal Protective Equipment (PPE) Gloves For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes

and non-intact skin Gown During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated Mask, eye protection During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal

intubation Component Recommendation Soiled equipment Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene Environmental Control

Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas Laundry Handle in a manner that prevents transfer of microorganisms to others and to the environment Needles and sharps Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed

scoop technique only; use safety features when available; place used sharps in puncture-resistant container Patient Resuscitation Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions Component Patient placement Recommendation

Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection. Respiratory hygiene/ Instruct symptomatic persons to cover mouth/nose cough etiquette when sneezing/coughing; use tissues and dispose in (source containment no-touch receptacle; observe hand hygiene after of infectious soiling of hands with respiratory secretions; wear respiratory surgical mask if tolerated or maintain spatial secretions in

separation, >3 feet if possible. symptomatic patients, beginning at initial point of encounter) RESPIRATORY HYGIENE/COUGH ETIQUETTE RESPIRATORY HYGIENE/COUGH ETIQUETTE Component Safe Injection Practices

Special Lumbar Procedures Recommendation Apply to the use of needles, cannulas that replace needles, and, where applicable intravenous delivery systems Use aseptic technique Needles, cannulae and syringes are sterile, singleuse items Use single-dose vials for parenteral medications whenever possible Do not administer medications form single-dose vials or ampules to multiple patients Do not keep multidose vials in the immediate

patient treatment area Do not use bags or bottles of IV solution as a common source of supply for multiple patients Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space TRANSMISSION BASED PRECAUTIONS Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, and are used when the route(s) of transmission

are not completely interrupted using Standard Precautions alone. Standard Precautions Transmission Based Precautions Isolation Precautions CRITERIA FOR ASSIGNING TRANSMISSION-BASED

PRECAUTIONS Category is assigned if there was strong evidence for person-to-person transmission Category assignment reflects predominant mode(s) of transmission If no evidence of person-to-person transmission via major routes, use Standard Precautions Low risk for person-to-person transmission and no evidence of health-care associated transmission, use Standard Precautions ROUTES OF TRANSMISSION

Direct Contact Indirect Contact Droplet Airborne (Aerosol) Private room or Cohort Gown and gloves prior to entry Hand hygiene Dedicate equipment Disinfect shared equipment C. difficile

and Norovirus CONDITIONS OR DISEASES REQUIRING CONTACT PRECAUTIONS Disease/Condition Duration of Isolation Anitbiotic Resistant Bacteria MRSA, VRE, ESBL-E.coli, etc. Until symptoms resolve

Clostridium difficile (C. diff) 24-48 hours after symptoms resolve Norovirus 48 hours after symptoms resolve Scabies and Lice 24 hours after treatment started Viral Conjunctivitis (pink eye)

Until symptoms resolve RESIDENT REQUIREMENTS CONTACT PRECAUTIONS Stay in Room, unless allowed to participate in activities Wash hands frequently Leaving Room Before and after activities Before and after eating After using bathroom Do not share personal items (razors, towel, etc.) with other residents

Surgical mask prior to entry No special ventilation Private room or Cohort Hand hygiene Residents use mask outside of room CONDITIONS OR DISEASES REQUIRING DROPLET PRECAUTIONS Disease/Condition Duration of Isolation

Seasonal Influenza Pandemic influenza Review the CDC seasonal guidance: for 2016-2017 Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a health care facility. Droplet precautions for 5 days from onset of symptoms

Meningococcal Diseases: meningitis, pneumonia For 24 hours after treatment has started MRSA pneumonia For duration of illness (also use Contact Precautions) Strep Throat For 24 hours after treatment has started

Rhinovirus (cold) For duration of illness RESIDENT REQUIREMENTS DROPLET PRECAUTIONS Stay in Room, unless necessary for therapy or treatment Wear a surgical mask when being transported outside of room. Wash hands frequently Leaving Room Before and after activities

Before and after eating After using bathroom Observe Respiratory Hygiene/Cough Etiquette Private room only Room requires Negative airflow pressure Doors must remain closed Everyone must wear an N95 respirator Limit the movement and transport of the Resident Hand hygiene before and after

TUBERCULOSIS Facility does not have a dedicated negative pressure room: Transfer resident to a facility capable of managing and evaluating resident Be sure policy is included in your plan Facility does have negative pressure room: Follow Airborne Precautions CHICKENPOX AND SHINGLES Disease/Condition Type and Duration of Isolation

Chickenpox (varicella) Airborne and Contact until lesions are dry and crusted Shingles (Herpes zoster. Varicella zoster) Localize in patient with intact immune system with lesions that can be contained/covered Standard Precautions Disseminated disease in any patient

Airborne and Contact precautions for duration of illness Localized disease in immunocompromised patient until disseminated infection ruled out Airborne and Contact precautions for duration of illness Non-immune healthcare personnel should not care for residents with Chickenpox or Shingles

SYNDROMIC AND EMPIRIC APPLICATION OF TRANSMISSION-BASED PRECAUTIONS Diagnosis requires lab confirmation Culture-based lab test require 2 or more days Precautions should be implemented while awaiting results Based on clinical presentation and likely pathogen Reduces transmission opportunities Clinical Syndrome or Condition Potential Pathogens Empiric Precautions (always

includes Standard Precautions Enteric Pathogens Contact Precautions Diarrhea Acute diarrhea with infectious cause is incontinent or diapered patient Rash or Exanthems, generalized, unknown etiology Petechial/Ecchmotic w/ fever

Neisseria meningitides Droplet Precautions for 1st 24hrs of antimicrobial therapy Vesicular Varicella-zoster, herpes simplex, vaccinia viruses Airborne plus Contact precautions Tb, Respiratory Viruses, S. pneumoniae, S. aureus

Airborne Precautions plus contact Staphylococcus aureus, group A streptococcus Contact Precautions Add Droplet for the first 24 hours of antimicrobial therapy if group A strep disease suspected Respiratory Infections Cough/fever/upper lobe infiltrate Skin or Wound Infection

Abscess or draining wound that cannot be covered DISCONTINUING TRANSMISSION-BASED PRECAUTIONS Remain in effect for limited period of time (i.e. while the risk for transmission persist or for the duration of illness) Disease specific recommendations in Appendix A of guideline Type and duration of precautions COMMUNICATING PRECAUTIONS

You must post the sign on the door. Airborne Droplet Contact Room Airborne Infectious

Isolation (AII) room preferred; private room; door closed Private Room Preferred; door may remain open Private room preferred: Either disposable single-use or dedicated use of patient care equipment to one resident

Hand Hygiene Standard Precautions Standard Precautions Standard Precautions Gloves Standard Precautions Standard Precautions

Wear gloves upon entry and discard before leaving Gown Standard Precautions Standard Precautions Wear gown upon entry and discard before leaving

Mask N-95 respirator or PAPR prior to entry Surgical mask upon entry Standard Precautions Eye Protection Standard Precautions

Standard Precautions Standard Precautions MANAGEMENT OF MULTI-DRUG RESISTANT ORGANISMS 2006 GROWING COMPLEXITY IN THE NH RESIDENT POPULATION Increased post-acute care population

Growing medical complexity Increased exposure to devices, wounds, and antibiotics High prevalence of multidrug-resistant organisms EPIDEMIOLOGICALLY IMPORTANT PATHOGENS Any infectious agent that have one or more of the following characteristics

Propensity for transmission within facilities Antimicrobial resistance implications Associated with serious disease; increased morbidity and mortality A newly discovered or re-emerging pathogen MORE ON EPIDEMIOLOGICALLY IMPORTANT PATHOGENS Some really bad pathogens are not multi-drug resistant (MDRO) Norovirus Group A strep C. difficile

Similar strategies used to control MDROs used to control pathogens other than MDROs ABCS OF MDROS Bacteria Abbreviation Antibiotic Resistance Staphylococcus aureus

MRSA Methicillin-resistant Enterococcus (faecalis/faecium) VRE Vancomycin-resistant Enterobacteraceae (E. coli/Klebsiella, etc)

CRE (KPC) Carbapenem-resistant Pseudomonas/ Acinetobacter MDR Many drug classes MDRO DEVELOPMENT HEALTHCARE SETTINGS Antibiotic pressure

Device utilization ANTIBIOTIC PRESSURE HOW RESISTANCE DEVELOPS IN BIOFILMS A THIN COATING CONTAINING BIOLOGICALLY ACTIVE AGENTS, WHICH COATS THE SURFACE OF STRUCTURES SUCH AS THE INNER SURFACES OF CATHETER, TUBE, OR OTHER IMPLANTED OR INDWELLING DEVICE. Bacteria with biofilms grow differently than free floating bacteria Antibiotics cannot penetrate the biofilm Bacteria within a biofilm talk to each other and share

traits that allow some to become resistant MDROS SPREAD IN HEALTHCARE SETTINGS Resident to resident transmission via healthcare providers hands Environmental/equipment contamination BACTERIAL CONTAMINATION OF HANDS PRIOR TO HAND HYGIENE IN A LTCF Gram negative were the most common bacteria cultured from hands

Most Gram negative bacteria live in the bowels or colonize the urine!! Mody L, et al. Infect Control Hosp Epi. 2003; 24:165-71 Stiefel U, et al. ICHE 2011;32:185-187 ENVIRONMENT-TO-HAND-TO-PATIENT 40% 45% Pathogens can be transferred from healthcare surfaces to HCP hands without direct patient contact

RESERVOIR OF MDROS X marks the location where VRE was isolated in the room Image from Abstract: The risk of hand and glove contamination after contact with a VRE + patient environment. Hayden M, ICAAC, 2001, Chicago, Il. SURVIVAL OF PATHOGENS ON SURFACES Pathogen

Survival MRSA 7 days 7 months VRE 5 days 4 months Acinetobacter 3 days -5 months

C. difficile (spores) 5 months Norovirus 12 28 days Kramer A, et al (2006). BMC Infect Dis; 6:130 THOROUGHNESS OF CLEANING Mean = 32%

Carling P, et al. APIC, 2012 INCREASED RISK FROM PRIOR OCCUPANT Otter J, et al. Infect Control Hosp Epidemiol. 2011; 32:687-699 KEY MDRO PREVENTION STRATEGIES Assessing hand hygiene practices Quickly reporting MDRO lab results Implementing Contact Precautions Recognizing previously colonized residents Strategically place residents based on MDRO risk factors Careful device utilization Antibiotic stewardship

Inter-facility communication REPORTING AND RECOGNITION OF MDRO LAB RESULTS Facilities should have a protocol for rapidly reporting positive MDRO lab results to clinicians Facilitates quick initiation of interventions Consider empiric precautions while awaiting lab results Contact precautions for resident with diarrhea PRECAUTIONS IN LTCF

CDC SAYS HICPAC, Management of MDROs in healthcare settings, 2006 DIFFICULTIES WITH CONTACT PRECAUTIONS Lack of private rooms and limited ability to move residents Determining the duration of Contact Precautions Unable to restrict resident mobility and socialization/therapy for long periods Unlikely to document clearance of carriage

Large population of residents with unrecognized MDRO carriage RECOGNIZING PRIOR COLONIZATION Residents can be colonized with MDROs for months Identifying previously colonized or infected residents allows for timely interventions Knowledge allows for planning the safest care For every known MDRO carrier, there are probably 3 others we dont know

RESIDENT PLACEMENT MDRO When single patient rooms are available assign priority for these rooms to individuals with known or suspected MDRO colonization or infection When not available, cohort patients with the same MDRO in the same room When cohorting (patients with the same MDRO) is not possible, place MDRO patients in rooms with ones who are at low risk for acquisition of MDROs and associated adverse outcomes from infection and are likely to have

short length of stay CDC: Management of MDROs in Healthcare Settings, 2006 PLACEMENT OF RESIDENTS BASED ON RISK FACTORS Avoid placing 2 high-risk residents together Safer to cohort low-risk and high-risk residents Dont change stable room assignments based on culture results unless it poses new risk Long-term Roommates have already shared organisms in the past (even if you just learned about it)

HIGH-RISK RESIDENTS CONTACT PRECAUTIONS DURING DIRECT CARE High-risk exposures for MDRO transmission if known carrier and high-risk for acquisition if non-carrier Presence of wounds (fresh/new, multiple, increased stage/size, active drainage) Indwelling devices (IV lines, urinary catheters, tracheostomy, PEG tubes) Incontinence Current antibiotic use Dementia RESIDENT CHARACTERISTICS TO CONSIDER THE 5 CS

Cognitive function (understands directions) Cooperative (willing and able to follow directions) Continent (of urine or stool) Contained (secretions, excretions, or wounds) Cleanliness (capacity for personal hygiene) Kellar M. APIC Infection Connection. Fall 2010 ed. WHEN TO USE CONTACT PRECAUTIONS AND RESTRICTED MOVEMENT Active symptoms of a contagious infection Nausea/vomiting New or worsening diarrhea New or worsening respiratory symptoms

New, undiagnosed fever Precautions and restrictions are time limited Infection is ruled out and/or symptoms resolve WHEN TO DISCONTINUE CONTACT PRECAUTIONS Resume Standard Precautions once high-risk exposures or active symptoms have discontinued Communication to care-givers and clear documentation of rationale is key

PRACTICAL TIPS Maintain ongoing database of residents with history of MDRO carriage (known colonization or infection) Incorporate risk factors for MDRO carriage and acquisition into care planning Have protocols for implementing and discontinuing Contact Precautions Assess staff knowledge of MDRO transmission and steps for prevention


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