HICPAC Recommendations on Surveillance for MDROs

The Centers for Disease Control and Prevention’s new draft guidelines for patient isolation have been criticized for not being aggressive enough in identifying and eradicating patient reservoirs of multidrug-resistant organisms (MDROs). However, the guidelines include a section on enhanced surveillance and infection control measures for ICPs who want to ratchet up their efforts against MDROs. For the various recommendation rankings and references please consult the "intensified interventions" section starting on p. 87 of the draft.1 The recommendations include:

Surveillance

A. Calculate and analyze prevalence and incidence rates of targeted MDRO infection/colonization in at-risk populations; when possible, distinguish colonization from infection.

1. Use single isolates from each patient.

2. Increase frequency of compiling/monitoring antimicrobial susceptibility summary reports, as indicated by rate of increase in incidence of target MDROs.

B. Implement lab protocols for storing isolates of selected MDROs for molecular typing when needed to confirm transmission or to monitor for epidemiologic purposes in a health care setting.

C. Develop/implement protocols to obtain surveillance cultures for target MDROs from patients in at-risk populations (e.g., patients in ICU, burn, oncology units; transfers from long-term care facilities and hemodialysis centers), as defined within the local institution.

1. Obtain surveillance cultures from areas of skin breakdown and draining wounds. In addition, include the following sites according to target MDROs.

a. For methicillin-resistant staphylococcus aureus (MRSA): anterior nares; throat and perirectal or perineal may be added to increase the yield.

b. For vancomycin-resistant enterococci (VRE), multidrug-resistant gram-negative bacilli (MDR-GNB): stool, rectal, or perirectal.

2. Obtain surveillance cultures at the time of admission to a high-risk area (e.g., ICU); especially culture patients previously known to be infected or colonized with the target MDRO or patients arriving from units or facilities with high endemic rates of the target MDRO.

D. Conduct culture surveys to assess the efficacy of the enhanced MDRO control interventions.

1. Conduct unit-specific point-prevalence culture surveys of the target MDRO to determine if transmission has decreased or ceased.

2. Repeat point-prevalence culture surveys at routine intervals (e.g., weekly, biweekly, or monthly) and at time of patient discharge or transfer until transmission has ceased.

3. Ensure culture data provide colonization status of roommates and other patients with substantial exposure to patients with known MDRO infection/ colonization.

E. Obtain cultures of health care personnel for target MDROs only when there is epidemiologic evidence implicating the health care staff member as a source of ongoing transmission.

F. Implement systems to monitor changes in MDRO incidence and prevalence after reducing the intensity of MDRO control efforts.

Enhanced infection control precautions

A. Patient placement: Implement interim policies for patient admissions, placement, and staffing as needed to prevent transmission of problem MDRO.

1. Place MDRO patients in single-patient rooms when available.

2. Cohort patients with same MDRO in segregated areas (e.g., rooms, bays, patient care areas).

3. When transmission continues despite cohorting patients, assign dedicated nursing staff (and other staff if possible) to the care of MDRO patients only.

4. Close unit or facility to new admissions if transmission continues despite the implementation of the intensified infection control measures described.

B. Implement contact precautions routinely for all patients colonized or infected with target MDROs. Don gowns and gloves before or upon entry to the patient’s room or cubicle due to possible contamination of environmental surfaces and medical equipment, especially those in close proximity to the patient.

C. When active surveillance cultures are obtained as part of MDRO control program, implement contact precautions until the surveillance culture obtained on admission is reported negative for the target.

D. No recommendation for universal glove and/or gown use in high-risk units in acute care hospitals. (unresolved issue)

E. Masks are not recommended for routine use upon room entry by health care workers to prevent transmission of MDROs from patient to health care worker and resulting nasal colonization. Use masks to prevent transmission of MRSA, vancomycin-intermediate susceptible S. aureus, and vancomycin-resistant S. aureus when aerosol-generating procedures (e.g., wound irrigation, oral suctioning, intubation, nebulizer respiratory therapy treatments, bronchoscopy) are performed and in circumstances where there is evidence of transmission from aerosolization from heavily colonized sources (e.g., burn wounds).

Reference 

1. Centers for Disease Control and Prevention. Healthcare Practices Infection Control Advisory Committee (HICPAC). Draft Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2004. Atlanta: 2004. Web: www.cdc.gov/ncidod/hip/isoguide.htm.