CDC: Go to 'intensified interventions' if needed

A stepwise approach increasing in rigor

New guidelines by the Centers for Disease Control and Prevention on control of multidrug resistant pathogens (MDROs) include a section on "intensified interventions" such as active surveillance cultures (ASC). The CDC recommendations in this area include the following:

  • Develop and implement protocols to obtain 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). Category IB (Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.)
  • Obtain ASC from areas of skin breakdown and draining wounds. In addition, include the following sites according to target MDROs:

— For MRSA: Sampling the anterior nares is usually sufficient; throat, endotracheal tube aspirate, percutaneous gastrostomy sites, and perirectal or perineal cultures may be added to increase the yield. Swabs from several sites may be placed in the same selective broth tube prior to transport. Category IB

— For VRE: Stool, rectal, or perirectal samples should be collected. Category IB

— For MDR-GNB: Endotracheal tube aspirates or sputum should be cultured if a respiratory tract reservoir is suspected, (e.g., Acinetobacter spp., Burkholderia spp.). Category IB.

  • Obtain surveillance cultures for the target MDRO from patients at the time of admission to high-risk areas, e.g., ICUs, and at periodic intervals as needed to assess MDRO transmission. Category IB
  • Conduct culture surveys to assess the efficacy of the enhanced MDRO control interventions. Conduct serial (e.g., weekly, until transmission has ceased and then decreasing frequency) unit-specific point prevalence culture surveys of the target MDRO to determine if transmission has decreased or ceased. Category IB
  • Repeat point-prevalence culture surveys at routine intervals or at time of patient discharge or transfer until transmission has ceased. Category IB
  • If indicated by assessment of the MDRO problem, collect cultures to assess the colonization status of roommates and other patients with substantial exposure to patients with known MDRO infection or colonization. Category IB
  • Obtain cultures of health care personnel for target MDRO when there is epidemiologic evidence implicating the health care staff member as a source of ongoing transmission. Category IB
  • Implement Contact Precautions routinely for all patients colonized or infected with a target MDRO. Category IA (Strongly recommended for implementation and strongly supported by well designed experimental, clinical, or epidemiologic studies.)
  • Because environmental surfaces and medical equipment, especially those in close proximity to the patient, may be contaminated, don gowns and gloves before or upon entry to the patient's room or cubicle. Category IB
  • 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. Category IB
  • Implement policies for patient admission and placement as needed to prevent transmission of a problem MDRO. Category IB
  • Place MDRO patients in single-patient rooms. Category IB
  • Cohort patients with the same MDRO in designated areas (e.g., rooms, bays, patient care areas. Category IB
  • When transmission continues despite adherence to Standard and Contact Precautions and cohorting patients, assign dedicated nursing and ancillary service staff to the care of MDRO patients only. Some facilities may consider this option when intensified measures are first implemented. Category IB
  • Stop new admissions to the unit of facility if transmission continues despite the implementation of the enhanced control measures described above. (Refer to state or local regulations that may apply upon closure of hospital units or services.) Category IB